Health inspection·April 14, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 4/13/2024, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 23's room, observed the resident's urinary catheter drainage bag hanging on the left lower part of the bed, visible from the doorway and without a dignity bag. LVN 1 stated the urinary catheter drainage bag should have been covered with dignity bag to protect the privacy of the resident and to promote the resident's right to a dignified existence. Residents Affected - Few During an interview on 4/14/2024, at 7:37 p.m., with the Nurse Manager (NM), the NM stated staff should have placed a dignity bag on the resident's urinary catheter drainage bag to provide dignity to Resident 23. The NM stated without the dignity bag, the resident's urine in the drainage bag is visible to visitors and other residents' family members. A review of the facility's policy and procedure titled, Standards of Care- Sub Acute (is intensive, but to a lesser degree than acute care), last revised on 3/2024, indicated an individualized plan of care is implemented for residents requiring an indwelling catheter that includes use of a dignity cover to protect the resident's privacy and dignity. 2. A review of Resident 238's Face Sheet indicated the facility admitted the resident on 2/4/2024, with diagnoses including of respiratory failure. A review of Resident 238's H&P, dated 2/5/2024, indicated the resident had a history of cerebrovascular accident (CVA, an interruption in the flow of blood to cells in the brain) and pulmonary embolism (a sudden blockage of a blood vessel in the lung). The H&P indicated the resident moves all extremities, no focal deficits (is not specific to a certain area of the brain), and non-verbal. A review of Resident 238's MDS, dated [DATE], indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident had hemiplegia (one-sided muscle paralysis or weakness) or hemiparesis (weakness of one entire side of the body). During a concurrent observation and interview on 4/13/2024, at 8:49 a.m., in Resident 238's room, observed the resident's head of bed (HOB) elevated 80 to 90 degrees and Certified Nursing Assistant 1 (CNA 1) standing over the resident, while assisting the resident with feeding. CNA 1 stated he should have sat on an eye level with the resident to provide the resident dignity. CNA 1 stated standing over the resident while feeding the resident conveys disrespect to the resident. During an interview on 4/14/2024, at 7:37 p.m., with the Nurse Manager (NM), the NM stated CNA 1 should have sat on a chair within eye level with Resident 238 while assisting the resident to eat to convey respect to the resident. The NM also stated sitting at an eye level keeps the staff aware when the resident was choking or not swallowing the food. A review of the Lippincott procedure Manual provided by the facility titled, Feeding, last revised on 12/11/2023, indicated meeting such patient's nutritional needs requires determining the patient's food preferences; feeding the patient in a friendly, unhurried manner; encouraging self-feeding whenever possible to promote independence and dignity; and documenting intake and output. Position a chair next to the patient's bed so you can sit comfortably if you need to assist with feeding. Face the patient during feeding, make eye contact, and use a gentle tone of voice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 2 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to notify the physician of one of one sampled resident's (Resident 37) who continued to have blood in the urine (hematuria) with presence of clots. Resident 37, who had an indwelling urinary catheter (IUC, a hollow flexible tube inserted in the bladder [the organ that stores urine] to drain urine) and was on blood thinner medication, was having hematuria from 1/12/2024 at 11:40 a.m. to 1/15/2024 and the attending physician (Physician 1) was not informed. As a result, on 1/15/2024 at 9:11 p.m., Resident 37 required emergency transfer to General Acute Care Hospital 1 (GACH 1) where Resident 37 was found with elevated body temperature (fever) and abdominal distention (abnormally swollen outward) requiring removal of the IUC with significant hematuria draining immediately after its removal. Resident 37 required intermittent catheterization (draining urine by passing a catheter through the urethra [the tube between the bladder and the external part of the body, which allows urine to be eliminated from the bladder] into the bladder which is removed after the urine has been drained) obtaining 800 milliliters (ml, unit of measure) of dark red urine. Resident 37 was diagnosed with septic shock (a life-threatening widespread infection causing organ failure and dangerously low blood pressure), urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that conducts urine from the bladder to the outside of the body] and infect the urinary tract), and pneumonia (an infection of one or both lungs caused by bacteria, viruses, or fungi). Cross reference F690. Findings: A review of Resident 37's admission Record indicated the facility admitted Resident 37 on 12/27/2023 with diagnoses including ischemic stroke (when a blood clot, known as a thrombus, blocks or plugs an artery leading to the brain), paroxysmal atrial fibrillation (when a person has an irregular heartbeat in the upper chambers of the heart), and acute respiratory failure (a serious condition that makes it difficult to breathe on your own). Resident 37 was dependent on a ventilator (a machine used to help a patient breathe). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/3/2024, indicated Resident 37 had severe cognitive impairment (involving conscious intellectual activity such as thinking, reasoning, or remembering). The MDS indicated Resident 37 was dependent on staff for all activities of daily living (ADLs, such as oral hygiene, toilet use, bathing, dressing, etc.). The MDS further indicated Resident 37 was admitted to the facility with an IUC. A review of Resident 37's Physician Order, dated 12/27/2023, indicated Apixaban (Eliquis, blood thinner [anticoagulant] used to treat and prevent blood clots and to prevent stroke) 5 milligram (mg - unit of measurement) tablet 5 mg twice daily for atrial fibrillation. A review of Resident 37's Physician Order, dated 12/28/2023. indicated to insert an IUC for acute urinary retention (inability to urinate) and/or obstruction (blockage). A review of Resident 37's Physician Order, dated 1/2/2024, indicated to hold (not to administer) Eliquis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 3 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Actual harm Residents Affected - Few A review of Resident 37's Physician Progress Note, dated 1/10/2024, indicated to start continuous bladder irrigation (CBI - is used to reduce the risk of clot formation and IUC patency by continuously irrigating the bladder via a three?way catheter [allows fluid to flow into and out of the bladder simultaneously]) due to Resident 37's IUC bag having blood-tinged urine; continue to hold Eliquis, and would re-evaluate on Friday (1/12/2024). A review of Resident 37's Physician Order, dated 1/10/2024, indicated CBI management as follows: - Run CBI at a rate to always keep pink or clearer. - Do not let CBI run out. - Do not let blood clots form in bladder or tubing. - Do not remove IUC without physician's order. - If new onset of heavy or uncontrolled blood in urine appears, notify the physician. A review of Resident 37's Nurse Progress Note, dated 1/11/2024 at 6:48 p.m., indicated urine had been clear since start of CBI, Physician 1 was informed and ordered to hold the CBI but if Resident 37 started having hematuria, continue with the CBI. A review of Resident 37's Physician Progress Note, dated 1/12/2024 timed at 2:31 p.m., indicated Resident 37's urine was clear, re-start Eliquis, and monitor for hematuria. A review of Resident 37's Intake and Output indicated the urine characteristics was described as red, light, and with clots or red/pink on 1/12/2024 at 11:40 a.m. and at 9:42 p.m.; on 1/13/2024 at 11 a.m.; on 1/14/2024 at 1:55 a.m., at 11:34 a.m., and at 10:10 p.m.; and on 1/15/2024 at 11:30 a.m. A review of Resident 37's Respiratory Therapist Progress Note, dated 1/15/2023 timed at 7:29 p.m., indicated Resident 37 was on the ventilator, hyperventilating (an abnormally rapid rate), respiratory rate in the high 50s (normal rate 12 to 16 breaths per minute), normal oxygen saturation (O2 Sat, normal above 92 %), and to monitor at bedside. A review of Resident 37's Respiratory Therapist Progress Note, dated 1/15/2023 timed at 7:50 p.m., indicated Resident 37 continued to hyperventilate with respiratory rate in the low 60s. A review of Resident 37's Nurses Progress Note, dated 1/15/2023 timed at 7:55 p.m., indicated Resident 37 appeared to have shortness of breath and the heart rate was 155 beats per minutes (bpm, normal range 60 to 100). Physician 1 was informed and ordered to transfer Resident 37 via paramedics (healthcare professionals trained to give emergency medical care to people who are injured or ill). A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 timed at 9 p.m. , described Resident 37's urine output was dark red with foul odor. A review of Resident 37's GACH 1 Emergency Department (ED ) Progress Noted, dated 1/15/2024 at 9:23 p.m., indicated a Computed Tomography (CT - an imaging test that helps healthcare providers detect diseases and injuries) scan of Resident 37 showed inflammation around the bladder which could represent urinary tract infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 4 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Actual harm Residents Affected - Few A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 at 9:23 p.m., indicated Resident 37's body temperature was 103 degrees Fahrenheit (ºF, normal range between 97 ºF and 99 ºF; the heart rate was 150 bpm, the respiratory rate was 41 breath per minute, and the blood pressure (is the pressure of circulating blood against the walls of blood vessels) was 158/114 millimeters of mercury (mmHg, unit of pressure; normal range 120/80 to 139/89 ). A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 timed at 11:49 p.m., indicated Resident 37 arrived hot to touch, abdomen distended and firm, IUC in place with drainage bag to gravity with 100 ml with tea-colored urine. At 9:45 p.m., IUC removed with significant hematuria (blood in urine) drainage from penis immediately after removal. Intermittent catheterization (draining urine by passing a catheter through the urethra into the bladder; the catheter is removed after the urine has been drained) removed 800 ml (the bladder can store up to 700 ml of urine in men) of dark red output, an IUC was inserted and drained 200 ml of dark sanguineous (with blood) urine. A review of Resident 37's GACH 1 record of the Pulmonary and Critical Care Consultation note, dated 1/16/2024 at 8 a.m. indicated Resident 37 was diagnosed with pneumonia, septic shock, abdominal distention, and hematuria. A review of Resident 37's GACH 1 History and Physical, dated 1/20/2024, included in the Infections Disease Assessment and Plan that Resident 37 had septic shock and UTI. During an interview on 4/14/2024 at 6:41 p.m., the Nurse Manager (NM) stated Resident 37 had hematuria from 1/12/2024 to 1/15/2024 and Physician 1 should have been notified because this was a change of condition. The NM stated Physician 1 needed to be notified as Resident 37 was back on Eliquis and continued bleeding. During an interview on 4/14/2024 at 7:51 p.m., Physician 1 stated licensed nurses did not inform him that Resident 37 continued to have hematuria for him to stop the Eliquis and transfer Resident 37 to a hospital sooner if the bleeding did not stop. A review of the current facility-provided policy and procedure (P&P) titled, Change of Condition, Notification (Sub Acute), last revised on 3/2024. indicated to ensure that the attending physician and responsible party are promptly notified upon significant change in the resident's condition. 1. Notify the resident's primary physician for the following conditions: B. Any sudden and/or marked adverse change in vital signs (are measurements of the body's most basic functions including body temperature, blood pressure, pulse and respiratory [breathing] rate), symptoms, or a significant divergence from the resident's established pattern of behavior. A review of the current facility-provided P&P titled, Indwelling Urinary Catheter Care and Management, last revised on 12/10/2023, indicated monitor intake and output, as ordered. Monitor for changes in urine output, including volume and color. Notify practitioner of abnormal findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 5 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) to three out of four sampled residents (Residents 24, 23, and 5) investigated during review of physical restraints care area by: Residents Affected - Some 1. Failing to complete an assessment for risk of entrapment prior to use of four bed siderails (SR) up (raised [up] position on bilateral [two sides] upper [area including arms, shoulders, and head] and bilateral lower [area including legs]). 2. Failing to obtain a physician's order for the use of four bed SR up and bed alarms (warn caregivers when residents leave or attempt to leave their beds). 3. Failing to obtain an informed consent prior to use of four bed SR up while in bed and bed alarms. These deficient practices placed the resident at risk for restriction from freedom of movement, decline in physical functioning, psychosocial harm, physical harm from entrapment, and death. Cross reference F700 Findings: 1. A review of Resident 24's Face Sheet indicated the facility originally admitted the resident on 7/16/2020 and readmitted the resident on 3/31/2022 with diagnoses including traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain which may result to disability or death), dysphagia (a condition in which swallowing is difficult or painful), percutaneous endoscopic gastrotomy (PEG - also known at GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement, and chronic respiratory failure (a long-term condition in which the lungs have a hard time loading the blood with oxygen which may result to low oxygen level). A review of Resident 24's History and Physical (H&P), dated 11/3/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/29/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 24's Morse Fall Risk Assessment every shift dated 4/11/2024, 4/12/2024, 4/13/2024, and 4/14/2024, indicated the resident was a medium risk for falls and a high risk for injury. A review of Resident 24's Order Reports did not indicate an order for four bed SR up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 6 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 24's every shift assessment by licensed nurses did not indicate the resident was assessed for possible entrapment with the use of four bed SR up prior to use. During a concurrent observation and interview on 4/13/2024 at 10:15 a.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 24 in bed with four SR up. LVN 3 stated the resident places her right leg over the SR most of the time and placing four SR in raised up position is for the safety of the resident. LVN 3 stated the resident is at risk for falls and the SR prevent the resident from falling. During a concurrent observation and interview on 3/13/2024 at 10:39 a.m., with Registered Nurse 2 (RN 2), RN 2 stated Resident 24's four bed SR were placed in raised position while in bed for the resident's safety, to prevent falls and possibly injury as resident moves a lot in the bed. During a concurrent interview and record review on 4/13/2024 at 4:00 p.m., with the Infection Preventionist (IP), Resident 24's medical record including assessments, physician orders and informed consents were reviewed. The IP verified the resident did not have an assessment, physician's order, and consent for the use of four bed SR up while in bed because the facility does not consider SR as restraints. During an interview on 4/14/2024 at 1:15 p.m., with the Nurse Clinician (NC), the NC stated the use four SR up while the resident is in bed is considered use of a restraint. The NC stated there should have been an order from the physician and assessment for entrapment risk for SR use prior to use of four SR up. During an interview on 4/14/2024 at 1:17 p.m., with the Nurse Manager (NM), the NM stated placing the resident's all four SR up is considered use of a restraint and there should have been an order from the physician and assessment for entrapment risk for SR use. The NM stated it is important to notify the Resident 24's representative of the risks and benefits of using four SR up so they (representative) would be aware of the potential risks from using the SR such as restriction of movement, decline in functioning and entrapment which may lead to injuries. A review of the facility's recent policy and procedure titled, Restraint Use (Sub Acute), last revised on 2/2024, indicated the following: It is the policy of general acute care hospital 1(GACH 1) to guide care givers on appropriate and safe management of residents with restraints and utilization of least restrictive alternatives. Ensure safe and ethical practice for the use of physical restraints, that no person will be restrained against their will for any period of time longer than necessary. Restraints are considered medical devices and are only used in the event that the patient is a danger to self or others. Consent for restraint is signed by legal representative/decision-maker. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 7 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 - Level of Harm - Minimal harm or potential for actual harm The licensed nurse will assess the patient and attempt to find less restrictive alternatives to restraint. - Residents Affected - Some Licensed healthcare practitioner order is required; orders for restraints obtained by telephone will be signed by the physician within five days; restraints are reordered every 30 days if continued need is assessed. Documentation on restraints will include device(s): a. Bed rails X 4 b. Mittens, including Peek-a-Boo mitt. c. Mittens d. Soft wrist restraints e. Assessment for continued need 2. A review of Resident 23's Face Sheet indicated the facility admitted the resident on 3/13/2024, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History and Physical (H&P), dated 4/3/2024, indicated the resident had a history of post traumatic cervical-spine injury (involves damage to any part of the spinal cord) and quadriplegia (a life-altering condition that results in a loss of control of both arms and both legs). The H&P indicated the resident was on a ventilator (a machine that helps a person breathe) with occasional grunting. A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/20/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 8 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 23's Fall Risk Assessment (FRA), dated 4/14/2024, indicated the resident was a medium risk for fall and at high risk for falls with injury. The FRA included the documentation of the application of the bed alarms. The FRA did include documentation of the resident using four side rails up in bed. A review of Resident 23's Care Plan titled, Problem: Fall Injury Risk, undated, indicated an intervention to avoid use of devices that minimize mobility such as restraints. During a concurrent observation and interview on 4/13/2024, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 23's room, observed Resident 23 in bed with four SR in raised position and a bed alarm in place. LVN 1 stated the resident's bed had all four side rails up and a bed alarm in place to prevent injuries resulting from falls. LVN 1 stated placing all 4 side rails up is considered use of a restraint. LVN 1 stated she is unsure if placement of bed alarm is considered a restraint. LVN 1 stated the bed alarm is to alert the staff if the resident is getting out of bed. LVN 1 stated a physician's order and consent from the resident's representative should be obtained prior to SR use. During a review of Residents 23's Physical Chart on 4/13/2024, at 4:37 p.m., there was no documented evidence a consent for use of four side rails up and bed alarm was obtained from the resident and or the resident's representative. During an interview on 4/14/2024, at 1:17 p.m., with the Nurse Manager (NM), the NM stated placing the resident's all four SR up is considered use of a restraint. The NM stated a physician's order, an assessment for entrapment risk, and consent from the resident or the resident representative (RR) should be in place prior to use of side rails. The NM stated the resident, or the RR should be informed of the risk and the benefits of using the restraints prior to application. The NM stated the bed alarms are used to notify the nurse if the resident is getting out of the bed and is not considered a restraint. The NM stated the application of four side rails up prevents the resident from getting out of bed thus hindering the resident from moving freely. The NM stated hindering the resident movement could potentially cause debilitation and injuries. A review of the facility's recent policy and procedure titled, Restraint Use (Sub Acute), last revised on 2/2024, indicated in keeping with the mission and values of General Acute Care Hospital 1 (GACH 1) to guide care givers on appropriate and safe management of residents with restraints and utilization of least restrictive alternatives. To ensure safe and ethical practice for the use of physical restraints in the Sub-Acute Unit and that no person will be restrained against their will for any period of time longer than necessary. Restraints are considered medical devices and are only used in the event that the patient is a danger to self or others. Consent for restraint is signed by legal representative/decision-maker. The licensed nurse will assess the patient and attempt to find less restrictive alternatives to restraint. Licensed healthcare practitioner order is required; orders for restraints obtained by telephone will be signed by the physician within five days; restraints are reordered every 30 days if continued need is assessed. Documentation on restraints will include device(s): a. Bed rails X 4 b. Mittens, including Peek-a-Boo mitts c. Mittens (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 9 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 d. Soft wrist restraints Level of Harm - Minimal harm or potential for actual harm e. Assessment for continued need Residents Affected - Some 3. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/28/2021, with diagnoses including gastrointestinal (GI, relating to, or including both the stomach and intestine) bleed. A review of Resident 5's H&P, dated 8/18/2023, indicated the resident had a history of alcohol abuse, and had a pedestrian accident sustaining bilateral subarachnoid hemorrhage (SAH, a bleeding in the space below one of the thin layers that cover and protect the brain), left subdural hemorrhage (SDH, a buildup of blood on the surface of the brain), with multiple facial bone fracture (partial or complete break in the bone). The H&P indicated the resident was awake and interactive with agitation and delirium (a mental state in which a person is confused and has reduced awareness of their surroundings). A review of Resident 5's MDS, dated [DATE], indicated the resident sometimes makes self-understood and understand others. The MDS indicated the resident had behavioral symptoms not directed towards others. The MDS indicated the resident was on a bed alarm. A review of Resident 5's FRA, dated 4/14/2024, indicated the resident was assessed as medium risk for fall and use of bed alarm was in place, The FRA did not indicate use of all four side rails up. A review of Resident 5's Care Plan titled, Problem: Fall Injury Risk, initiated on 8/2/2023, indicated the resident had a fall episode, found resident sitting on the floor at the right side of the bed on 8/2/2023. The Care Plan indicated the resident had lack of safety awareness/judgment due to impaired cognition (a term for mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) and needed assistance during transfer from bed to shower gurney or vice versa. During a concurrent observation and interview on 4/13/2024, at 10:55 a.m., with Licensed Vocational Nurse 2 (LVN 2), in Resident 5's room, observed Resident 5 in bed with four SR in raised position and a bed alarm in place. LVN 2 stated the resident's bed had all four side rails up and a bed alarm is in place to prevent the resident from falling. LVN 2 stated use of side rails and bed alarm do not need a physician's and consent from the resident's representative. LVN 2 stated he does not consider use of four side rails up and bed alarms as restraints. LVN 2 stated the side rails are up so the resident will not be able to get out of bed and the bed alarms are to alert the staff if the resident is getting out of bed, to prevent falls. During a concurrent interview and record review on 4/13/2024, at 2:13 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 5's All Active Orders, Flow Sheet, and Media. RN 4 stated there was no documented evidence of informed consent for side rails and entrapment risk assessment for side rail use. RN 4 stated the resident's bed had all four side rails up and a bed alarm is in place to prevent falls. During a review of Residents 5's Physical Chart on 4/13/2024, at 4:37 p.m., there was no documented evidence a consent for use of four side rails up and bed alarm was obtained from the resident and or the resident's representative. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 10 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/14/2024, at 1:15 p.m., with the Nurse Clinician (NC), the NC stated use of four side rails up is considered use of a restraint and required an order from the physician. The NC also stated the resident should have an assessment for side rail use to ensure safety. The NC stated use of four side rails up and bed alarm was implemented to prevent Resident 5 from getting out of the bed and to alert the staff if the resident was getting out of bed. The NC stated the use of bed alarm is not considered use of a restraint. During an interview on 4/14/2024, at 1:17 p.m., with the Nurse Manager (NM), the NM stated placing the resident's all four SR up is considered use of a restraint. The NM stated a physician's order, an assessment for entrapment risk, and consent from the resident or the resident representative (RR) should be in place prior to use of side rails. The NM stated the resident, or the RR should be informed of the risk and the benefits of using the restraints prior to application. The NM stated the bed alarms are used to notify the nurse if the resident is getting out of the bed and is not considered a restraint. The NM stated the application of four side rails up prevents the resident from getting out of bed thus hindering the resident from moving freely. The NM stated hindering the resident movement could potentially cause debilitation and injuries. A review of the facility's recent policy and procedure titled, Restraint Use (Sub Acute), last revised on 2/2024, indicated in keeping with the mission and values of General Acute Care Hospital 1 (GACH 1) to guide care givers on appropriate and safe management of residents with restraints and utilization of least restrictive alternatives. To ensure safe and ethical practice for the use of physical restraints in the Sub-Acute Unit and that no person will be restrained against their will for any period of time longer than necessary. Restraints are considered medical devices and are only used in the event that the patient is a danger to self or others. Consent for restraint is signed by legal representative/decision-maker. The licensed nurse will assess the patient and attempt to find less restrictive alternatives to restraint. Licensed healthcare practitioner order is required; orders for restraints obtained by telephone will be signed by the physician within five days; restraints are reordered every 30 days if continued need is assessed. Documentation on restraints will include device(s): a. Bed rails X 4 b. Mittens, including Peek-a-Boo mitts c. Mittens d. Soft wrist restraints e. Assessment for continued need FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 11 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and screening tool) assessments were successfully transmitted timely to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers major healthcare programs) for four out of 14 sampled residents (Residents 12, 18, 23, and 27) investigated under the resident assessment care area. Residents Affected - Some This deficient practice had the potential to negatively affect the provision of necessary care and services needed by the residents. Findings: a.A review of Resident 12's Face Sheet indicated the facility originally admitted the resident on 12/6/2021 and readmitted the resident on 11/22/2022 with diagnoses including traumatic brain injury (acquired brain injury that occurs when a sudden trauma causes damage to the brain which may result to disability or death), cardiac arrest (a condition that occurs when the heart suddenly and unexpectedly stops pumping and unable to deliver blood to the body), and percutaneous endoscopic gastrotomy (PEG - also known at GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement. A review of Resident 12's MDS dated [DATE], indicated the resident was in a persistently vegetative state and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a concurrent interview and record review, on 4/14/2024 at 8:06 p.m., reviewed Resident 12's list of Completed MDS Assessments tracking log in the electronic health record (EHR) with the Minimum Data Set Coordinator (MDSC). The MDSC verified that Resident 12's annual and quarterly MDS assessments dated 3/1/2023, 6/1/2023, 9/1/2023, and 12/1/2023 status remained exported. The MDSC stated after exporting the assessments, there will be a validation report after successful transmission from the CMS and needed to be reconciled by the MDSC for CMS to accept the assessment. The MDSC verified the CMS final validation report for Resident 12's MDS assessments dated 3/1/2023, 6/1/2023, 9/1/2023, and 12/1/2023 indicated there have been no CMS final validation report for the assessments; hence, transmissions were not successful and not accepted. The MDSC stated the validation report should have been reconciled by the previous MDSC for the assessments to be accepted to prevent delay in the provision of necessary care and services the resident needs. During a concurrent interview and record review on 4/14/2022 at 8:45 p.m., reviewed Resident 12's list of Completed MDS Assessments tracking log in the electronic health record (EHR) with the Nurse Manger (NM). The NM verified Resident 12's MDS assessments dated 3/1/2023, 6/1/2023, 9/1/2023, and 12/1/2023 remained in the exported status and stated the facility has a new Minimum Data Set Coordinator (MDSC) as the previous MDSC left abruptly without a handoff report of pending assessments. The NM stated the previous MDSC should have completed the process of submission and transmission of MDS assessments. The NM stated MDS assessments give a picture of what are the necessary care and services the residents needs and if assessments were not accepted by the CMS, there could be a potential delay in the provision of care for the residents if not addressed timely and appropriately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 12 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 Level of Harm - Potential for minimal harm A review of the facility's policy and procedure titled, Minimum Data Set (MDS) - Sub Acute, last reviewed 3/2024, indicated a purpose to comply with state and federal regulations for the documentation of care, electronic transmission, and protection of clinical information in skilled nursing facilities. The policy indicated all MDS assessments are transmitted as per schedule on Attachment A which indicated assessment transmissions should be no later than 14 calendar days after completion. Residents Affected - Some b. A review of Resident 18's Face Sheet indicated the facility originally admitted the resident on 9/25/2020 and readmitted the resident on 6/2/2023 with diagnoses including chronic respiratory failure ((a long-term condition in which the lungs have a hard time loading the blood with oxygen which may result to low oxygen level), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), and percutaneous endoscopic gastrotomy (PEG - also known at GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement. A review of Resident 18's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 11/29/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a concurrent interview and record review on 4/14/2024 at 8:06 p.m., reviewed Resident 18's list of Completed MDS Assessments tracking log in the electronic health record (EHR) with the Minimum Data Set Coordinator (MDSC). The MDSC verified that Resident 18's quarterly and annual MDS assessments dated 12/4/2022, 3/4/2023, 8/29/2023, and 11/29/2023 remained exported. The MDSC stated after exporting the assessments, there will be a validation report after successful transmission from the CMS and needed to be reconciled by the MDSC for CMS to accept the assessment. The MDSC verified the CMS final validation report for Resident 18's quarterly and annual MDS assessments indicated there have been no CMS final validation report for the assessment; hence, assessment transmission assessment was not successful and not accepted. The MDSC stated the validation report should have been reconciled by the previous MDSC for the annual assessment to be accepted to prevent delay in the provision of necessary care and services the resident needs. During a concurrent interview and record review on 4/14/2022 at 8:45 p.m., reviewed Resident 18's list of Completed MDS Assessments tracking log in the electronic health record (EHR) with the Nurse Manger (NM). The NM verified Resident 18's annual MDS assessments dated 12/4/2022, 3/4/2023, 8/29/2023, and 11/29/2023 remained exported and stated the facility has a new Minimum Data Set Coordinator (MDSC) as the previous MDSC left abruptly without a handoff report of pending assessments. The NM stated the previous MDSC should have completed the process of submission and transmission of MDS assessments. The NM stated MDS assessments give a picture of what are the necessary care and services the residents needs and if assessments were not accepted by the CMS, there could be a potential delay in the provision of care for the residents if not addressed timely and appropriately. A review of the facility's policy and procedure titled, Minimum Data Set (MDS) - Sub Acute, last reviewed 3/2024, indicated a purpose to comply with state and federal regulations for the documentation of care, electronic transmission, and protection of clinical information in skilled nursing facilities. The policy indicated all MDS assessments are transmitted as per schedule on Attachment A which indicated annual assessments transmission should be no later than 14 calendar days after completion. c. A review of Resident 23's Face Sheet indicated the facility admitted the resident on 3/3/2024, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 13 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 with a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe). Level of Harm - Potential for minimal harm A review of Resident 23's MDS, dated [DATE], indicated the resident rarely to never had the ability to make self-understood and understand others. Residents Affected - Some During a concurrent interview and record review on 4/14/2024, at 3:12 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed with the MDSC the Annual Centers for Medicare and Medicaid Services (CMS) Validation Report of Resident 23, with Assessment Reference Date (ARD) of 8/20/2023, with a status of exported, indicated there had been no CMS final validations reports imported for this assessment. The MDSC stated that after exporting the assessment, she should have gone back to her assessments and reconciled the assessments and checked against the validation report; after it was reconciled the status of the MDS assessments should have changed to accepted. The MDSC also stated that she just assumed the role and there was no endorsement done form the previous MDS coordinator. A review of the facility's recent policy and procedure titled, Minimum Data Set (MDS)- (Sub Acute), last reviewed on 3/2024, indicated to ensure all residents in the Sub-acute Unit have the Minimum Data Set (MDS) completed and transmitted timely as per the Federal and State mandatory guidelines. To comply with state and federal regulations for the documentation of care, electronic transmission, and protection of clinical information in skilled nursing facilities. All required MDS assessments are transmitted as per schedule on Attachment A. RAI OBRA- required Assessment Summary indicated on Annual (Comprehensive) transmission date no later than- care plan completion date +14 calendar days. d. A review of Resident 27's Face Sheet indicated the facility admitted the resident on 8/23/2023, with a diagnosis of respiratory failure. A review of Resident 27's MDS, dated [DATE], indicated the resident rarely to never had the ability to make self-understood and understand others. During a concurrent interview and record review on 4/14/2024, at 8:40 p.m., with the MDSC, reviewed with the MDSC the Annual CMS Validation Report of Resident 23, with ARD of 11/215/2023, with a status of exported, indicated there had been no CMS final validations reports imported for this assessment. The MDSC stated that after exporting the assessment, she should have gone back to her assessments and reconciled the assessments and checked against the validation report; after it was reconciled the status of the MDS assessments should have changed to accepted. The MDSC also stated that she just assumed the role and there was no endorsement done form the previous MDS coordinator. The MDSC stated that it was important to reconcile and submit the MDS assessments timely so the biller can see what Health Insurance Prospective Payment System ([NAME], represents specific sets of patient characteristics health insurers use to make payment determinations) code or code for payment to bill. A review of the facility's recent policy and procedure titled, Minimum Data Set (MDS)- (Sub Acute), last reviewed on 3/2024, indicated to ensure all residents in the Sub-acute Unit have the Minimum Data Set (MDS) completed and transmitted timely as per the Federal and State mandatory guidelines. To comply with state and federal regulations for the documentation of care, electronic transmission, and protection of clinical information in skilled nursing facilities. All required MDS assessments are transmitted as per schedule on Attachment A. RAI OBRA- required Assessment Summary indicated on Annual (Comprehensive) transmission date no later than- care plan completion date +14 calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 14 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm Based on observation, record review, and interview the facility failed to ensure the Minimum Data Set (MDS-a resident assessment and care screening tool) accurately reflected the resident's status in one of four sampled residents (Resident 24) investigated during review of physical restraints by failing to document the resident's use of a mitten restraint (used to prevent residents who are prone to disrupting medical treatment or to self-harm from pulling out any lines or tubes such as feeding tubes, intravenous [administered into a vein] lines) Residents Affected - Some This deficient practice has the potential to negatively affect Resident 24's plan of care and delivery of necessary care and services. Findings: A review of Resident 24's Face Sheet indicated the facility originally admitted the resident on 7/16/2020 and readmitted the resident on 3/31/2022 with diagnoses including traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain which may result to disability or death), dysphagia (a condition in which swallowing is difficult or painful), percutaneous endoscopic gastrotomy (PEG - also known at GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement, and chronic respiratory failure (a long-term condition in which the lungs have a hard time loading the blood with oxygen which may result to low oxygen level). A review of Resident 24's History and Physical (H&P), dated 11/3/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/29/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS did not indicate the resident was using a limb restraint. A review of Resident 24's Order Report dated 4/2/2024, indicated an order: - May apply right peek-a-boo mitt (hand mitten) to prevent self-harm/injury by pulling tubes/medical devices for 30 days. A review of Resident 24's Facility Verification of Informed Consent for Use of Restraints or prolonged use of a device dated 4/1/2024, 3/1/2024, 2/1/2024, 1/17/2024, indicated informed consent was obtained by the physician from Family Member 1 (FM 1). A review of Resident 24's care plan on restraint/seclusion use for patient safety initiated 1/17/2024 with target date 7/14/2024 indicated may apply right peek-a-boo mitt to prevent self-harm/injury by pulling tubes/medical devices for 90 days. During a concurrent observation and interview on 4/13/2024 at 10:09 a.m., with Registered Nurse 2 (RN 2), observed Resident 24 wearing a mitten on the right hand. RN 2 stated the peek-a-boo mitten restraint was applied for the resident's safety; prevent the resident from removing the oxygen via the tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 15 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 trachea [windpipe] from outside the neck). Level of Harm - Potential for minimal harm During an interview on 4/14/2024 at 3:30 p.m., with Registered Nurse 5 (RN 5), RN 5 stated restraint orders are renewed every month after an evaluation by the physician and a new informed consent needs to obtained from the family. Residents Affected - Some During a concurrent interview and record review on 4/14/2024 at 8:50 p.m., with the Director of Nursing (DON), Resident 24's MDS assessment was reviewed. The DON verified the MDS was coded inaccurately because it did not reflect the resident's use of a restraint (peek-a-boo mitten). The DON stated not coding the MDS accurately had the potential to delay provision of care. A review of Long Term-Care Resident Assessment Instrument 3.0 User's Manual (a manual published by the Centers for Medicare & Medicaid Services [CMS - the federal agency that provides health coverage to more than 160 million and works in partnership with the entire health community to improve quality, equity, and outcomes in the healthcare system] to disseminate information to facilitate accurate and effective resident assessment practices in long term-care facilities), last updated 10/2023, indicated federal regulations require that the assessment accurately reflects the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 16 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of Resident 37's admission Record indicated the facility admitted Resident 37 on 12/27/2023 with diagnoses including ischemic stroke (when a blood clot, known as a thrombus, blocks or plugs an artery leading to the brain), paroxysmal atrial fibrillation (when a person has an irregular heartbeat in the upper chambers of the heart), and acute respiratory failure (a serious condition that makes it difficult to breathe on your own). Resident 37 was dependent on a ventilator (a machine used to help a patient breathe). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/3/2024 indicated Resident 37 cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 37 was dependent on oral hygiene, toileting hygiene, showering, upper and lower body dressing and putting on and taking off footwear. The MDS further indicated Resident 37 was admitted to the facility with an indwelling urinary catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine). A review of Resident 37's Physician Order, dated 12/27/2023, indicated Apixaban (Eliquis, blood thinner [anticoagulant] used to treat and prevent blood clots and to prevent stroke) 5 milligram (mg - unit of measurement) tablet 5 mg twice daily for atrial fibrillation. A review of Resident 37's Physician Order, dated 1/2/2024, indicated to hold (not to administer) Eliquis. A review of Resident 37's Physician Order dated 12/27/2023 indicated insert indwelling urinary catheter one time due to critically ill with need for accurate input and output. A review of Resident 37's Physician Order dated 12/28/2023 indicated: -Insert indwelling urinary catheter time for acute urinary retention and or obstruction. - indwelling urinary catheter care 16 French for retention until discontinued. A review of Resident 37's Physician Order dated 1/10/2024 indicated continuous bladder irrigation management. -run continuous bladder irrigation (CBI) at a rate to keep pink or clearer at all times. -Do not let CBI run out. -Do not let blood clots form in bladder or tubing. -Do not remove catheter without physician's order. -if new onset of heavy or uncontrolled blood in urine appears notify provider. During a concurrent interview and record review on 4/14/2024 at 6:36 p.m. with the Nurse Manager (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 17 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (NM), the NM stated there was no care plan for Resident 37's indwelling urinary catheter. The NM stated there should be a care plan addressing the resident's indwelling catheter because the care plan determines the plan, interventions, evaluation, and assessments regarding treatment. The NM stated without a care plan, they are unable to set the goals of treatment and implement interventions. During a concurrent interview and record review on 4/14/2024 at 8:35 p.m. with the Nurse Manager (NM), Resident 37's care plans were reviewed. The NM stated there was no care plan for the use of Eliquis. The NM stated without a care plan there is no guidelines or goals for treatment. The NM stated not having a care plan for the use of Eliquis had the potential for not monitoring the resident for bleeding. A review of the current facility-provided policy and procedure (P&P) titled, Documentation, Clinical (Sub Acute), last revised on 3/2024 indicated all clinical documentation reflects a systemic, interdisciplinary approach to resident care. Care is based on outcome/goals listed in the care plan. An interdisciplinary care plan is constructed within 7 days of admission. This care plan outlines focused problems and interventions selected by the health care team. For residents staying longer than 7 days. 3. A review of Resident 24's Face Sheet indicated the facility originally admitted the resident on 7/16/2020 and readmitted the resident on 3/31/2022 with diagnoses including traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain which may result to disability or death), dysphagia (a condition in which swallowing is difficult or painful), percutaneous endoscopic gastrotomy (PEG - also known at GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement, and chronic respiratory failure (a long-term condition in which the lungs have a hard time loading the blood with oxygen which may result to low oxygen level). A review of Resident 24's History and Physical (H&P), dated 11/3/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/29/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 24's care plan did not indicate a care plan was developed for SR and bed alarm use. During a concurrent observation and interview on 4/13/2024 at 10:15 a.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 24 in bed with four SR up. LVN 3 stated the resident is at risk for falls and the SR prevent the resident from falling. During a concurrent interview and record review on 4/13/2024 at 4:00 p.m., Resident 24's medical record was reviewed with the Infection Preventionist (IP). The IP verified the there was no care plan for SR use. During an interview on 4/14/2024 at 1:15 p.m., the Nurse Clinician (NC), stated a care plan should have been developed for the use of SRs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 18 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/14/2024 at 8:45 p.m., the Nurse Manager (NM) verified there was no care plan addressing the use of SRs. The NM stated a care plan is important because it provides instructions to the healthcare team on how to properly care for Resident 24. A review of the facility's recent policy and procedure titled, Documentation, Clinical (Sub Acute), last reviewed and approved on 3/2024, indicated the following: General acute care hospital 1 (GACH 1) ensures accurate clinical documentation in the resident's electronic health record. GACH 1 ensures all information pertinent to each resident's individual care are accurately and effectively communicated. An interdisciplinary care plan is constructed within seven (7) days of admission and outlines focused problems and interventions selected by the health care team. For residents staying longer than 7 days, the facility follows the procedure for MDS. Based on observation, interview, and record review the facility failed to: 1. Develop and implement a care plan for bed alarm (device that warns caregivers when residents leave or attempt to leave their beds) use to two of four sampled residents investigated during review of restraints (Residents 23 and 5). 2. Develop and implement a comprehensive person-centered care plan for use of four bed siderails (SR) to three of four sampled residents (Resident 23, 24 and 5) investigated during review of restraints. These deficient practices had the potential for residents to not receive the proper and necessary care regarding SRs and bed alarm use with the potential to result in injury of the resident by failing to provide ongoing assessment, monitoring, and re-evaluation of SRs and restraints. 3. Ensure Resident 37 had a care plan addressing the use of apixaban (Eliquis-a FDA-approved to treat and prevent certain types of dangerous blood clots that can block blood vessels in your body) to one out of two sampled residents investigated during review of closed records. 4. Ensure Resident 37 had a care plan addressing the use of an indwelling catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine) to one out of one sampled resident being investigated during review of review of closed records. These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 19 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. A review of Resident 23's Face Sheet indicated the facility admitted the resident on 3/13/2024, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History and Physical (H&P), dated 4/3/2024, indicated the resident had a history of post traumatic cervical-spine injury (involves damage to any part of the spinal cord) and quadriplegia (a life-altering condition that results in a loss of control of both arms and both legs). The H&P indicated the resident was on a ventilator (a machine that helps a person breathe) with occasional grunting. A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/20/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. A review of Resident 23's Fall Risk Assessment (FRA), dated 4/14/2024, indicated the resident was a medium risk for fall and at high risk for falls with injury. The FRA included the documentation of the application of the bed alarms. The FRA did include documentation of the resident using four side rails up in bed. A review of Resident 23's Care Plan titled, Problem: Fall Injury Risk, undated, indicated an intervention to avoid use of devices that minimize mobility such as restraints or indwelling urinary catheter (a catheter that drains urine from the bladder into a bag outside of the body). During a concurrent observation and interview on 4/13/2024, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 23's room, observed Resident 23 in bed with four SR in raised position and a bed alarm in place LVN 1 stated there was no care plan created for SR and bed alarm use. During an interview on 4/14/2024, at 7:47 p.m., with the Nurse Manager (NM), the NM stated a care plan should have been developed and implemented for Resident 23's SR and bed alarm use. The NM stated care plan establishes goals and treatment of care that serves as their guide on how to care for the residents. The NM stated a care plan is needed to achieve quality of life. A facility's recent policy and procedure titled, Documentation, Clinical (Sub Acute), last revised on 3/2024, indicated an interdisciplinary care plan is constructed within 7 days of admission. This care plan outlines focused problems and interventions selected review of the by the health care team. For residents staying longer than 7 days, see procedure for Minimum Data Set (MDS). 2. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/28/2021, with diagnoses including gastrointestinal (GI, relating to, or including both the stomach and intestine) bleed. A review of Resident 5's H&P, dated 8/18/2023, indicated the resident had a history of alcohol abuse, and had a pedestrian accident sustaining bilateral subarachnoid hemorrhage (SAH, a bleeding in the space below one of the thin layers that cover and protect the brain), left subdural hemorrhage (SDH, a buildup of blood on the surface of the brain), with multiple facial bone fracture (partial or complete break in the bone). The H&P indicated the resident was awake and interactive with agitation and delirium (a mental state in which a person is confused and has reduced awareness of their surroundings). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 20 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 5's MDS, dated [DATE], indicated the resident sometimes makes self-understood and understand others. The MDS indicated the resident had behavioral symptoms such not directed towards others. The MDS indicated the resident was using a bed alarm. A review of Resident 5's FRA, dated 4/14/2024, indicated the resident was assessed as medium risk for fall and use of bed alarm was in place, The FRA did not indicate use of all four side rails up. During a concurrent observation and interview on 4/13/2024, at 10:55 a.m., with Licensed Vocational Nurse 2 (LVN 2), in Resident 5's room, observed Resident 5 in bed with four SR in raised position and a bed alarm in place. LVN 2 stated there was no care plan created for SR and bed alarm use. During a concurrent interview and record review on 4/13/2024, at 2:13 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 5's care plans. RN 4 stated care plans help the licensed nurses to communicate the plan of care to the healthcare team. RN 4 stated without the care plan they will not be able to evaluate the effectivity of the interventions provided to the resident. During an interview on 4/14/2024, at 7:47 p.m., with the Nurse Manager (NM), the NM stated a care plan should have been developed and implemented for SR and bed alarm use. The NM stated care plan establishes goals and treatment of care that serves as their guide on how to care for the residents. The NM stated a care plan is needed to achieve quality of life. A facility's recent policy and procedure titled, Documentation, Clinical (Sub Acute), last revised on 3/2024, indicated an interdisciplinary care plan is constructed within 7 days of admission. This care plan outlines focused problems and interventions selected review of the by the health care team. For residents staying longer than 7 days, see procedure for Minimum Data Set (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 21 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to three of three sampled residents (Residents 23, 27, and 14) being investigated under pressure ulcers by failing to consistently: Residents Affected - Some 1. Assess and follow facility's policy and procedure of taking pictures and documenting the measurement of the stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle) of Resident 23 on the sacrum (a triangular bone at the base of the spine) and the occipital area (the back of the head). 2. Assess and follow facility's policy and procedure of taking pictures and documenting the measurement of the stage 4 pressure injury of Resident 27 on the sacrum. 3. Assess and follow facility's policy and procedure of taking pictures and documenting the appearance of the moisture related skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents) on the sacral area of Resident 14. These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents. Findings: 1. A review of Resident 23's Face Sheet (admission Record) indicated the facility admitted the resident on 3/13/2024, with a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History & Physical (H&P), dated 4/3/2024, indicated the resident had history of sacral decubiti ulcers (damage to an area of the skin caused by constant pressure on the area for a long time) and venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart). The H&P indicated the resident was on a ventilator (a machine that helps a person breathe) with occasional grunting. A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/20/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 23 was incontinent of bowel (feces). The MDS also indicated Resident 23 was at risk of developing pressure ulcers/injuries and had two unhealed stage 4 pressure injuries with pressure ulcer/injury care. A review of Resident 23's Braden Scale Assessment (BSA), dated 4/14/2024, indicated the resident was bedfast, completely immobile, and high risk for pressure ulcer/injury. A review of Resident 23's All Active Orders, dated 3/16/2024, indicated an order for: -Wound care sacrococcyx (the tailbone) pressure injury stage 4 until discontinued. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 22 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Comments: Cleanse with normal saline (NS, mixture of water and salt commonly used for wound irrigation) pack with puracol (collagen dressing with the flexibility of application), moist gauze and cover with mepilex (foam dressing) every (q) shift and if needed (prn) if loose or soiled. Re-evaluate weekly. Associated wounds: wound 11/21/2022 pressure injury sacral spine. Residents Affected - Some -Wound care occipital healing pressure injury stage 4 until discontinued. Comments: Cleanse with NS, apply plurogel (a burn and wound dressing) to wound bed, cover with moist gauze and mepilex dressing daily and prn if loose or soiled. Re-evaluate weekly. Associated wounds: wound 11/21/2022 pressure injury occipital region. A review of Resident 23's Care Plans titled, Problem: Impaired Wound Healing, initiated on 8/25/2020, and Problem: Skin Injury Risk Increased, undated, indicated interventions to assess and monitor wound for signs of impaired healing (e.g., drainage or purulent exudate [fluid that leaks out of blood vessels into nearby tissues], absence of healing ridge, prolonged inflammatory response) and reassess skin (injury risk, full inspection) frequently (e.g., schedule interval, with change in condition) to provide optimal early detection and prevention. During a concurrent interview and record review on 4/14/2024, at 8:42 a.m., with Registered Nurse 1 (RN 1), reviewed the Lines/Drain/airway (LDA) flowsheet of Resident 23 with RN 1. RN1 stated she does weekly wound assessment, including taking pictures, wound measurements, reviewing and updating of the pressure injury care plan documented in the multidisciplinary care progress notes. RN 1 stated there were missing assessments and documentations on the following weeks: -3/24/2024 to 3/30/2024- wound assessment, measurement, picture, and care plan review documentation. -1/1/2024, 4/4/2024, and 4/10/2024 - care plan review and revision on the multidisciplinary care progress notes. RN 1 stated she was on vacation from 3/24/2024 to 3/30/2024 and she did not know why the wound assessments were not done. RN 1 stated that it was important to follow the weekly wound assessments and documentations to see if the wound was progressing, and to inform the doctor or the wound specialist to intervene if there was a worsening of the pressure injury. During an interview on 4/14/2024, at 7:49 p.m., the Nurse Manager (NM) stated the treatment nurses should make sure they perform weekly wound assessment, including taking pictures, wound measurements, reviewing and updating of the pressure injury care plan documented in the multidisciplinary care progress notes to monitor the wound for worsening or healing of the wound. The NM stated if there was worsening of pressure injury, timely assessment and reporting was very crucial so the interdisciplinary team can be informed, and the attending physician and the wound specialist can step in. The NM stated between 3/24/2024 to 3/30/2024 they were short staffed, their wound nurse was on vacation, they had a float nurse, and they got an acute nurse rehab float, and she did not do it. A review of the facility's recent policy and procedure titled, Pressure Injury and Skin Breakdown Assessment and Prevention, last revised on 12/2022, indicated under wound assessment, complete a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 23 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wound assessment for all identified wounds including: 8. Size in centimeters. A Wound certified Registered Nurse will review and validate all pressure injuries in the following categories: hospital-acquired pressure injuries (HAPIs), Stages 3 (full thickness tissue loss) and 4, deep tissue injury (DTIs, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters), Unstageable (obscured full-thickness skin and tissue loss), and any pressure injury that progresses/worsens from initial staging. The wound care RN upon consult will evaluate the wound(s) and develop a treatment plan of care and perform assessments as needed. Photographs will be taken of each wound weekly. Documentation to accompany photographs includes: a. Wound dimensions b. Wound descriptors as noted in the wound assessment. 2. A review of Resident 27's Face Sheet indicated the facility admitted the resident on 8/23/2023, with a diagnosis of respiratory failure. A review of Resident 27's H&P, dated 8/25/2023, indicated the resident had a history of diabetes mellitus (DM, occurs when the blood glucose, also called blood sugar is too high), obesity, and had a sacral decubitus stage 4. The H&P indicated Resident 27 was not following commands, had a weak cough and gag reflex. A review of Resident 27's MDS, dated [DATE], indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 27 was always incontinent of bowel. The MDS indicated Resident 27 was at risk for developing pressure ulcer/injuries and had one stage 4 pressure injury with pressure ulcer/injury care. A review of Resident 27's BSA, dated 4/14/2024, indicated the resident was bedfast and completely immobile. The BSA indicated Resident 27 was high risk for pressure injury development. A review of Resident 27's All Active Orders, dated 8/24/2023, indicated an order for wound care sacrococcyx pressure injury stage 4 until discontinued. Comments: Cleanse with NS. Pat dry, pack wound cavity with as many as can fit puracol, then moist gauze, cover with mepilex every Monday/Wednesday/Friday and prn if loose or soiled. Re-eval weekly. A review of Resident 27's Care Plan titled, Skin Injury Risk Increased, undated, indicated an intervention to reassess skin (injury risk, full inspection) frequently (e.g., scheduled interval, with change in condition) to provide optimal early detection and prevention. During a concurrent interview and record review on 4/14/2024, at 8:42 a.m., with RN 1, reviewed the LDA flowsheet of Resident 27 with RN 1. RN 1 stated there were missing assessments and documentations on the following weeks: -4/7/2024 to 4/13/2024- wound assessment, measurement, and care plan review documentation. -3/17/2024 to 3/23/2024, 3/10/2024 to 3/16/2024, 3/18/2024 to 3/24/2024, 1/21/2024 to 1/27/2024, and 12/31/2023 to 1/6/2024- care plan review and revision on the multidisciplinary care progress notes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 24 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some RN 1 stated that it was important to follow the weekly wound assessments and documentations to see if the wound was progressing, and to inform the doctor or the wound specialist to intervene if there was a worsening of the pressure injury. During an interview on 4/14/2024, at 7:49 p.m., with the Nurse Manager (NM), the NM stated the treatment nurses should make sure they perform weekly wound assessment, including taking pictures, wound measurements, reviewing and updating of the pressure injury care plan documented in the multidisciplinary care progress notes to monitor the wound for worsening or healing of the wound. The NM stated if there was worsening of pressure injury, timely assessment and reporting was very crucial so the interdisciplinary team can be informed, and the attending physician and the wound specialist can step in. The NM stated between 3/24/2024 to 3/30/2024 they were short staffed, their wound nurse was on vacation, they had a float nurse, and they got an acute nurse rehab float, and she did not do it. A review of the facility's recent policy and procedure titled, Pressure Injury and Skin Breakdown Assessment and Prevention, last revised on 12/2022, indicated under wound assessment, complete a wound assessment for all identified wounds including: 8. Size in centimeters. A Wound certified Registered Nurse will review and validate all pressure injuries in the following categories: hospital-acquired pressure injuries (HAPIs), Stages 3 (full thickness tissue loss) and 4, deep tissue injury (DTIs, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters), Unstageable (obscured full-thickness skin and tissue loss), and any pressure injury that progresses/worsens from initial staging. The wound care RN upon consult will evaluate the wound(s) and develop a treatment plan of care and perform assessments as needed. Photographs will be taken of each wound weekly. Documentation to accompany photographs includes: a. Wound dimensions b. Wound descriptors as noted in the wound assessment. 3. A review of Resident 14's Face Sheet indicated the facility admitted the resident on 3/24/2024, with a diagnosis of respiratory failure. A review of Resident 14's H&P, dated 3/25/2023, indicated the resident had a history of DM, and massive intraparenchymal hemorrhage in the left basal ganglia (bleeding into the brain parenchyma [functional tissue in the brain]). The H&P indicated Resident 14 had extensor posturing (an involuntary flexion or extension of arms and legs) on both upper extremities and withdraws on both lower extremities and was nonverbal. A review of Resident 14's MDS, dated [DATE], indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident was incontinent of urine and bowel. The MDS indicated Resident 14 was at risk for developing pressure ulcer/injuries and had a moisture associated skin damage (MASD) with pressure ulcer/injury care. A review of Resident 14's BSA, dated 4/14/2024, indicated the resident was bedfast with very limited mobility. The BSA indicated Resident 14 was high risk for pressure injury development. A review of Resident 14's All Active Orders, dated 8/26/2023, indicated an order for wound care, wound sacral MASD until discontinued. Comments: Cleanse with NS, pat dry, apply aquacel ag (a silver foam dressing), cover with mepilex (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 25 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 daily and prn if loose or soiled. Re-eval weekly. Level of Harm - Minimal harm or potential for actual harm A review of Resident 14's Care Plan titled, Problem: Skin Injury Risk Increased, last reviewed on 3/16/2024, indicated an intervention to reassess skin (injury risk, full inspection) frequently (e.g., scheduled interval, with change in condition) to provide optimal early detection and prevention. Residents Affected - Some During an interview and record review on 4/14/2024, at 9:30 a.m., with RN 1, reviewed the Media of Resident 14 with RN 1. RN 1 stated they do not measure the wound, but they take pictures weekly for MASD. RN 1 stated there were missing assessment and picture on the week of 3/4/2024 to 3/30/2024. During an interview on 4/14/2024, at 7:49 p.m., the Nurse Manager (NM) stated the treatment nurses should make sure they perform weekly wound assessment, including taking pictures, wound measurements, reviewing and updating of the pressure injury care plan documented in the multidisciplinary care progress notes to monitor the wound for worsening or healing of the wound. The NM stated if there was worsening of pressure injury, timely assessment and reporting was very crucial so the interdisciplinary team can be informed, and the attending physician and the wound specialist can step in. The NM stated between 3/24/2024 to 3/30/2024 they were short staffed, their wound nurse was on vacation, they had a float nurse, and they got an acute nurse rehab float, and she did not do it. A review of the facility's recent policy and procedure titled, Pressure Injury and Skin Breakdown Assessment and Prevention, last revised on 12/2022, indicated under wound assessment, complete a wound assessment for all identified wounds including: 8. Size in centimeters. A Wound certified Registered Nurse will review and validate all pressure injuries in the following categories: hospital-acquired pressure injuries (HAPIs), Stages 3 (full thickness tissue loss) and 4, deep tissue injury (DTIs, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters), Unstageable (obscured full-thickness skin and tissue loss), and any pressure injury that progresses/worsens from initial staging. The wound care RN upon consult will evaluate the wound(s) and develop a treatment plan of care and perform assessments as needed. Photographs will be taken of each wound weekly. Documentation to accompany photographs includes: a. Wound dimensions b. Wound descriptors as noted in the wound assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 26 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 37), who had an indwelling urinary catheter (IUC, a hollow flexible tube inserted in the bladder [the organ that stores urine] to drain urine), was on blood thinner medication, and had recent hematuria (blood in the urine) with presence of clots, received care and services to prevent complications including continued hematuria, urinary retention (inability to urinate) and/or obstruction (blockage), urinary tract infection (UTI infection that happens when germs enter the urethra [the tube that conducts urine from the bladder to the outside of the body], and infect the urinary tract). As a result, on 1/15/2024 at 9:11 p.m., Resident 37 required emergency transfer to General Acute Care Hospital 1 (GACH 1) where Resident 37 was found with elevated body temperature (fever), abdominal distention (abnormally swollen outward) required removal of the IUC with significant hematuria draining immediately after its removal. Resident 37 required intermittent catheterization (draining urine by passing a catheter through the urethra into the bladder which is removed after the urine has been drained) obtaining 800 milliliters (ml, unit of measure) of dark red urine with foul odor. Resident 37 was diagnosed with septic shock (a life-threatening widespread infection causing organ failure and dangerously low blood pressure), UTI, and pneumonia (an infection of one or both lungs caused by bacteria, viruses, or fungi). Cross reference F580. Findings: A review of Resident 37's admission Record indicated the facility admitted Resident 37 on 12/27/2023 with diagnoses including ischemic stroke (when a blood clot, known as a thrombus, blocks or plugs an artery leading to the brain), paroxysmal atrial fibrillation (when a person has an irregular heartbeat in the upper chambers of the heart), and acute respiratory failure (a serious condition that makes it difficult to breathe on your own). Resident 37 was dependent on a ventilator (a machine used to help a patient breathe). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/3/2024, indicated Resident 37 had severe cognitive impairment (involving conscious intellectual activity such as thinking, reasoning, or remembering). The MDS indicated Resident 37 was dependent on staff for all activities of daily living (ADLs, such as oral hygiene, toilet use, bathing, dressing, etc.). The MDS further indicated Resident 37 was admitted to the facility with an IUC. A review of Resident 37's Physician Order, dated 12/27/2023, indicated Apixaban (Eliquis, blood thinner [anticoagulant] used to treat and prevent blood clots and to prevent stroke) 5 milligram (mg - unit of measurement) tablet 5 mg twice daily for atrial fibrillation. A review of Resident 37's Physician Order, dated 12/28/2023, indicated to insert an IUC for acute urinary retention (inability to urinate) and/or obstruction (blockage). A review of Resident 37's Physician Order, dated 1/2/2024, indicated to hold (not to administer) Eliquis. A review of Resident 37's Physician Progress Note, dated 1/10/2024, indicated to start continuous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 27 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Actual harm bladder irrigation (CBI - is used to reduce the risk of clot formation and IUC patency by continuously irrigating the bladder via a three?way catheter [allows fluid to flow into and out of the bladder simultaneously]) due to Resident 37's IUC bag having blood-tinged urine; continue to hold Eliquis, and would re-evaluate on Friday (1/12/2024). Residents Affected - Few A review of Resident 37's Physician Order, dated 1/10/2024, indicated CBI management as follows: - Run CBI at a rate to always keep pink or clearer. - Do not let CBI run out. - Do not let blood clots form in bladder or tubing. - Do not remove IUC without physician's order. - If new onset of heavy or uncontrolled blood in urine appears, notify the physician. A review of Resident 37's Nurse Progress Note, dated 1/11/2024 at 6:48 p.m., indicated urine had been clear since start of CBI, Physician 1 was informed and ordered to hold the CBI but if Resident 37 started having hematuria, continue with the CBI. A review of Resident 37's Physician Progress Note, dated 1/12/2024 timed at 2:31 p.m., indicated Resident 37's urine was clear, re-start Eliquis, and monitor for hematuria. A review of Resident 37's Intake and Output indicated the urine characteristics was described as red, light, and with clots or red/pink on 1/12/2024 at 11:40 a.m. and at 9:42 p.m.; on 1/13/2024 at 11 a.m.; on 1/14/2024 at 1:55 a.m., at 11:34 a.m., and at 10:10 p.m.; and on 1/15/2024 at 11:30 a.m. A review of Resident 37's Respiratory Therapist Progress Note, dated 1/15/2023 timed at 7:29 p.m., indicated Resident 37 was on the ventilator, hyperventilating (an abnormally rapid rate), respiratory rate in the high 50s (normal rate 12 to 16 breaths per minute), normal oxygen saturation (O2 Sat, a test that measures the amount of oxygen being carried by red blood cells and the normal result is above 92 %), and to monitor at bedside. A review of Resident 37's Respiratory Therapist Progress Note, dated 1/15/2023 timed at 7:50 p.m., indicated Resident 37 continued to hyperventilate with respiratory rate in the low 60s. A review of Resident 37's Nurses Progress Note, dated 1/15/2023 timed at 7:55 p.m., indicated Resident 37 appeared to have shortness of breath and the heart rate was 155 beats per minute (bpm, normal range is 60 to 100). Physician 1 was informed and ordered to transfer Resident 37 via paramedics (healthcare professionals trained to give emergency medical care to people who are injured or ill). A review of Resident 37's GACH 1 Emergency Department (ED) Progress Notes, dated 1/15/2024 timed at 9 p.m., described Resident 37's urine output was dark red with foul odor. A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 at 9:23 p.m., indicated Resident 37's body temperature was 103 degrees Fahrenheit (ºF, normal range between 97 ºF and 99 ºF; the heart rate was 150 bpm, the respiratory rate was 41 breath s per minute, and the blood pressure (is the pressure of circulating blood against the walls of blood vessels) was 158/114 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 28 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 millimeters of mercury (mmHg, unit of pressure; normal range is 120/80 to 139/89 ). Level of Harm - Actual harm A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 timed at 11:49 p.m., indicated Resident 37 arrived hot to touch, abdomen distended and firm, IUC in place with drainage bag to gravity with 100 ml with tea-colored urine. At 9:45 p.m. IUC removed with significant hematuria (blood in urine) drainage from penis immediately after removal. Intermittent catheterization (draining urine by passing a catheter through the urethra into the bladder; the catheter is removed after the urine has been drained) removed 800 ml (the bladder can store up to 700 ml of urine in men) of dark red output, an IUC was inserted and drained 200 ml of dark sanguineous (with blood) urine. Residents Affected - Few A review of Resident 37's GACH 1 record of the Pulmonary and Critical Care Consultation note, dated 1/16/2024 at 8 a.m. indicated Resident 37 was diagnosed with pneumonia, septic shock, abdominal distention, and hematuria. A review of Resident 37's GACH 1 History and Physical, dated 1/20/2024, under Assessment and Plan indicated Resident 37 had septic shock and UTI. During an interview on 4/14/2024 at 6:41 p.m., the Nurse Manager (NM) stated Resident 37 had hematuria from 1/12/2024 to 1/15/2024 and Physician 1 should have been notified because this was a change of condition. The NM stated Physician 1 needed to be notified as Resident 37 was back on Eliquis and continued bleeding. During an interview on 4/14/2024 at 7:51 p.m., Physician 1 stated licensed nurses did not inform him that Resident 37 continued to have hematuria for him to stop the Eliquis and transfer Resident 37 to a hospital sooner if the bleeding did not stop. A review of the current facility-provided policy and procedure (P&P) titled, Change of Condition, Notification (Sub Acute), last revised on 3/2024. indicated to ensure that the attending physician and responsible party are promptly notified upon significant change in the resident's condition. 1. Notify the resident's primary physician for the following conditions: B. Any sudden and/or marked adverse change in vital signs (are measurements of the body's most basic functions including body temperature, blood pressure, pulse and respiratory [breathing] rate), symptoms, or a significant divergence from the resident's established pattern of behavior. A review of the current facility-provided P&P titled, Indwelling Urinary Catheter Care and Management, last revised on 12/10/2023, indicated monitor intake and output, as ordered. Monitor for changes in urine output, including volume and color. Notify practitioner of abnormal findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 29 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) for three of three sampled residents (Residents 24, 26, and 191) investigated under the tube feeding care area by: 1. Failing to ensure Resident 24's EF bottle indicated the correct date and time the current bottle was started, and the water flush bag indicated the date and time started and the rate prescribed by the physician. 2. Failing to ensure Resident 26's and 191's EF bottle indicated the rate as prescribed by the physician. 3. Failing to ensure Resident 26' and 191's water flush bag indicated the date and time started and the rate prescribed by the physician. These deficient practices had the potential to place Residents 24, 26, and 191 at risk for complications of enteral feeding such as diarrhea (loose, watery stools when you poop) or vomiting which may lead to dehydration (loss or removal of water). Findings: a. A review of Resident 24's Face Sheet (admission Record) indicated the facility originally admitted the resident on 7/16/2020 and readmitted the resident on 3/31/2022 with diagnoses including traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain which may result to disability or death), dysphagia (a condition in which swallowing is difficult or painful), percutaneous endoscopic gastrotomy (PEG - also known at GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement, and chronic respiratory failure (a long-term condition in which the lungs have a hard time loading the blood with oxygen which may result to low oxygen level). A review of Resident 24's History and Physical (H&P), dated 11/3/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 1/29/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 24's physician's order, dated 11/29/2023, indicated the following order: -Hydration/water tube feeding (TF) amount 200 milliliters (ml - a unit of measurement for liquids) every six (6) hours. -Continuous TF carbohydrate controlled: Diabetisource AC (a tube feeding formula made with a unique blend of carbohydrates that includes pureed fruits and vegetables to help with nutritional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 30 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 management of patients with diabetes); rate: 55 ml per hour for 22 hours per day. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 4/13/2024 at 10:18 a.m., Registered Nurse 2 (RN 2) verified Resident 24's EF bottle indicated a date of 4/14/2024 10 p.m. and the water flush bag did not indicate the date it was started. RN 2 stated the water flush bag and EF bottle should have been labelled properly so the staff would know when they were started and ensure the formula was not expired. Residents Affected - Some During a concurrent interview and interview on 4/14/2024 at 2:30 p.m., the Nurse Manager (NM) verified that the package insert for the water flush bag indicated not to use the bag for more than 24 hours. The NM stated the water flush bag should have been labeled with the date and time the formula was hung, and the rate prescribed by the physician so the staff would know when it was started and need to discard the bag after 24 hours. The NM stated the EF bottle should have been labeled with the correct date and time it was hung for other staff to know and ensure the formula was not expired. A review of the facility's procedure titled, Enteral Tube Feeding, continuous, gastrostomy, jejunostomy, last revised 12/11/2023, indicated the following: -Verify the practitioner's order, including the patient's identifiers; prescribed route based on the enteral tube tip's location; enteral feeding device; prescribed enteral formula; administration method, volume, rate; and type, volume, and frequency of water flushes. -The procedure indicated to compare the enteral formula container label with the order in the patient's medical record. -Make sure the enteral formula container is labeled with the date and time the formula was hung; administration route, rate, and duration (if cycled or intermittent); initials of the person who prepared, hung, and checked the enteral formula against the orders. b. A review of Resident 26's Face Sheet indicated the facility originally admitted the resident on 6/9/2021 and readmitted the resident on 1/2/2024 with diagnoses including cardiac arrest (a condition that occurs when the heart suddenly and unexpectedly stops pumping and unable to deliver blood to the body), PEG placement, and chronic respiratory failure. A review of Resident 26's H&P, dated 1/4/2024, indicated the resident was non-verbal and unable to follow commands. A review of Resident 26's MDS, dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and totally dependent on staff with all ADLs. A review of Resident 26's physician's order, dated 1/10/2024, indicated the following order: -Hydration/water tube feeding (TF) amount 200 milliliters (ml - a unit of measurement for liquids) every four (4) hours. -Continuous TF concentrated 1.5 kilocalories per milliliter (Kcal/ml - a food calorie): Nutren (calorically dense complete tube feeding formula for the nutritional management of those with limited fluid tolerance and increased energy needs); rate: 65 ml per hour for 22 hours per day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 31 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 4/13/2024 at 11:40 a.m., Licensed Vocational Nurse 3 (LVN 3) verified Resident 26's EF bottle did not indicate the rate prescribed by the physician. LVN 3 verified the water flush bag did not have a label indicating the resident's name, room number, rate prescribed by the physician, and the date and time the water flush bag was hung. LVN 3 stated all TF formulas and water flush bags should be labeled with the resident's name, room number, rate prescribed by the physician, and the date and time they were hung. so, everyone would know the correct amount of feeding and amount of water flushes the resident was receiving. During an interview on 4/14/2024 at 2:30 p.m., the Nurse Manager (NM) stated EF formula label should match the prescribed order by the physician. The NM stated the water flush bag should have been labeled with the date and time the formula was hung, and the rate prescribed by the physician so the staff would know when it was started and need to discard the bag after 24 hours. Th NM stated the EF bag should have the rate prescribed rate by the physician so other staff would know to ensure the resident was receiving the correct amount of feeding. A review of the facility's procedure titled, Enteral Tube Feeding, continuous, gastrostomy, jejunostomy, last revised 12/11/2023, indicated the following: -Verify the practitioner's order, including the patient's identifiers; prescribed route based on the enteral tube tip's location; enteral feeding device; prescribed enteral formula; administration method, volume, rate; and type, volume, and frequency of water flushes. -The procedure indicated to compare the enteral formula container label with the order in the patient's medical record. -Make sure the enteral formula container is labeled with the date and time the formula was hung; administration route, rate, and duration (if cycled or intermittent); initials of the person who prepared, hung, and checked the enteral formula against the orders. c. A review of Resident 191's Face Sheet indicated the facility admitted the resident on 6/6/2022 with diagnoses including traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain which may result to disability or death), gastrotomy tube (GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement, and chronic respiratory failure. A review of Resident 191's H&P, dated 2/28/2024, indicated the resident was unable to follow commands and opened eyes only intermittently. A review of Resident 191's MDS, dated [DATE], indicated the resident had severely impaired cognition and totally dependent on staff with all ADLs. A review of Resident 191's physician's order, dated 1/10/2024, indicated the following order: - Tube feeding adult formula standard Fibersource HN (a nutritionally complete, tube feeding formula with fiber for patients with normal or high calorie and/or protein requirements; 60 ml/hr; free water amount: 150 ml; free water frequency: every 4 hours. During a concurrent observation and interview on 4/13/2024 at 11:40 a.m., Licensed Vocational Nurse 3 (LVN 3) verified Resident 191's EF bottle did not indicate the rate prescribed by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 32 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm LVN 3 verified the water flush bag did not have a label indicating the resident's name, room number, rate prescribed by the physician, and the date and time the water flush bag was hung. LVN 3 stated all TF formulas and water flush bags should be labeled with the resident's name, room number, rate prescribed by the physician, and the date and time they were hung. so, everyone would know the correct amount of feeding and amount of water flushes the resident was receiving. Residents Affected - Some During an interview on 4/14/2024 at 2:30 p.m., the Nurse Manager (NM) stated EF formula label should match the prescribed order by the physician. The NM stated the water flush bag should have been labeled with the date and time the formula was hung, and the rate prescribed by the physician so the staff would know when it was started and need to discard the bag after 24 hours. Th NM stated the EF bag should have the rate prescribed rate by the physician so other staff would know to ensure the resident was receiving the correct amount of feeding. A review of the facility's procedure titled, Enteral Tube Feeding, continuous, gastrostomy, jejunostomy, last revised 12/11/2023, indicated the following: -Verify the practitioner's order, including the patient's identifiers; prescribed route based on the enteral tube tip's location; enteral feeding device; prescribed enteral formula; administration method, volume, rate; and type, volume, and frequency of water flushes. -The procedure indicated to compare the enteral formula container label with the order in the patient's medical record. -Make sure the enteral formula container is labeled with the date and time the formula was hung; administration route, rate, and duration (if cycled or intermittent); initials of the person who prepared, hung, and checked the enteral formula against the orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 33 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure residents resident receive care and services for the provision of parenteral fluids (medicines or fluids that go directly into the vein) consistent with professional standards of practice to two out of two sampled residents (Residents 21 and 238) investigated during random observations of residents receiving parenteral/intravenous (IV, within a vein) fluids by failing to label the peripheral IV (indwelling single-lumen plastic conduits that allow fluids, medications and other therapies such as blood products to be introduced directly into a peripheral vein) dressing with the date of when the IV was inserted or when the dressing was changed and the licensed nurse's initials who inserted the IV or changed the dressing. Residents Affected - Few The deficient practice had the potential for complications related to intravenous fluid administration such as infiltration, bruising, phlebitis (inflammation of a vein), and infections. Findings: 1. A review of Resident 21's Face Sheet indicated the facility admitted the resident on 12/1/2021, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 21's History and Physical (H&P), dated 1/24/2024, indicated the resident had a history of sepsis (the body's extreme response to an infection), on a ventilator (a machine that helps a person breathe) via tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). The H&P indicated the resident does not follow commands. A review of Resident 21's All Active Orders, dated 2/19/2022, indicated an order for hypoglycemia (low blood sugar) management until discontinued. If unable to eat, gastrointestinal (GI) tract unavailable of the patient is unconscious: -if a large bore intravenous (IV) or central line (a tube that doctors place in a large vein in the neck, chest, groin, or arm to give fluids, blood, medications or to do medical tests quickly) is already in place, infuse 25 grams (a unit of weight) (50 cubic centimeter [cc, a unit of volume]) of D50 (50% dextrose injection indicated in the treatment of low blood sugar) IV push within 3 to 9 minutes. During a concurrent observation and interview on 4/13/2024, at 10:39 a.m., with Respiratory Therapist 1 (RT 1), in Resident 21's room, observed an unlabeled peripheral IV line, gauge 22 (needle gauge size) on the resident's right arm. RT 1 stated the peripheral IV was not labeled with a date and was not initialed by the licensed nurse who inserted or changed the dressing of the peripheral IV. During an interview on 4/13/2024, at 10:42 a.m., with Registered Nurse 6 (RN 6), RN 6 stated the peripheral IV should have been labeled with the insertion date or when the dressing was changed so that staff will know when to start a new line or when to change the dressing. RN 6 stated not dating the peripheral IV can result in staff not knowing when to change the dressing or start a new line which had the potential to lead to an infection. 2. A review of Resident 238's Face Sheet indicated the facility admitted the resident on 2/4/2024, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 34 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 with diagnoses including respiratory failure. Level of Harm - Minimal harm or potential for actual harm A review of Resident 238's H&P, dated 2/5/2024, indicated the resident had a history of pulmonary embolism (a sudden blockage of a blood vessel in the lung) and septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). The H&P indicated the resident moves all extremities, no focal deficits (not specific to a certain area of the brain), and non-verbal. Residents Affected - Few A review of Resident 238's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/8/2023, indicated the resident rarely to never hand the ability to make self-understood and understand others. A review of Resident 238's All Active Orders, dated 2/4/2024, indicated an order for hypoglycemia management until discontinued. If unable to eat, GI tract unavailable of the patient is unconscious: -if a large bore IV or central line is already in place, infuse 25 grams (50 cc) of D50 IV push within 3 to 9 minutes. During a concurrent observation and interview on 4/13/2024, at 8:49 a.m., with Certified Nursing Assistant 2 (CNA 2), in Resident 238's room, observed a peripheral IV line, gauge 24 on Resident 238's right hand. CNA 2 stated the IV dressing did not have a date and did not have the licensed nurse's initials. CNA 2 stated the IV line was not dated. CNA 2 stated she knew that IV lines should be dated for infection control purposes, so the licensed nurses knew when to start a new IV or change the dressing. During an interview on 4/13/2024, at 11:38 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 328's peripheral IV line should be dated and initialed, so they know when to change the line, to prevent infection. During an interview on 4/14/2024, at 7:58 p.m., with the Nurse Manager (NM), the NM stated the peripheral IV line should be dated and initialed by the nurse who started the line or changed the dressing, so the licensed nurses know when to reinsert a new line or change the dressing. The NM stated not labeling the peripheral IV lines could potentially result in missed dressing care or new insertions which can lead to phlebitis (vein flammation) and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). A review of the facility's recent policy and procedure titled, Comprehensive Vascular Access Management, last reviewed on 5/2023, indicated frequency of dressing changes: a. Dressings are to be changed every seven (7) days or earlier if soiled, damp, or loose. b. Gauze dressings are to be changed every 48 hours and as needed. The dressing will be labeled, indicating the date of insertion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 35 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to one out of one sampled resident (Resident 34) investigated during review of respiratory care by failing to connect the trach collar (used to hold a tracheostomy tube [a tube constructed of polyvinyl chloride that is placed between the vocal cords through the wind pipe] in place) to the oxygen humidifier (medical devices used to humidify supplemental oxygen) and oxygen regulator to ensure delivery of oxygen required to keep the resident's oxygen saturation (O2 sat, measures what percentage of the blood is saturated with oxygen) above 92%. Residents Affected - Few The deficient practice had a potential to cause Resident 34 hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) resulting in respiratory problems. Findings: A review of Resident 34's Face Sheet indicated the facility admitted the resident on 11/8/2023, with diagnose including respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 34's History and Physical (H&P), dated 11/10/2023, indicated the resident had a fall and sustained traumatic brain injury (TBI, a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain). The H&P indicated the resident was awake but non-communicative. A review of Resident 34's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/1/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. A review of Resident 34's All Active Orders, dated 3/21/2024, indicated an order for: -Oxygen therapy until discontinued. Via trach mask or t-piece (allows for the delivery of oxygen therapy to residents who have had a tracheostomy [an opening surgically created through the neck into the windpipe to allow air to fill the lungs]), keep oxygen saturation (O2 sat, measures what percentage of the blood is saturated with oxygen) greater than (>) 92. A review of Resident 34's Care Plan titled, Problem: Device-Related Complication Risk (Artificial Airway), no date, indicated an intervention to assess and monitor airway and breathing for effective oxygenation and ventilation; maintain close surveillance for deterioration due to airway swelling or obstruction; signs may be subtle and provide humidification and evaluate need or suctioning to minimize risk of airway obstruction; regularly replace closed suction equipment. During an observation and interview on 4/13/2024, at 9:04 a.m., with Registered Nurse 1 (RN 1), in Resident 34's room, observed the resident's t-piece (an instrument used in weaning of a resident from a ventilator) not connected to the oxygen regulator. RN 1 stated the t-piece should be connected to the oxygen regulator with the humidifier to administer the prescribed oxygen concentration. RN 1 stated failure to connect the t-piece to the oxygen regulator could lead to respiratory distress. During an interview on 4/14/2024, at 7:59 p.m., with the Nurse Manager (NM), the NM stated the respiratory therapist who provided the breathing treatment should have checked if the t-piece was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 36 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete connected back to the oxygen regulator to ensure delivery oxygen to the resident. The NM stated not reconnecting the t-piece to the oxygen regulator was unsafe and can result in respiratory compromise. A review of the facility's recent policy and procedure titled, Respiratory Protocol to Evaluate and Treat (Adult), last reviewed on 6/2019, indicated the purpose of this policy is to define the scope and process of assessments on patient's ordered under Respiratory Protocol to Evaluate and Treat (RT to Evaluate and Treat). Event ID: Facility ID: 555074 If continuation sheet Page 37 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of four (4) bed side rails (SR) for three of four sampled residents (Resident 24, 23, and 5) investigated during review of physical restraints by: 1. Failing to conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from side rails. 2. Failing to review the risk and benefits of side rails with the resident or resident representative and obtain informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment). These deficient practices had the potential to result in psychosocial harm and physical harm from entrapment and death of residents. Cross Reference F604 Findings: 1. A review of Resident 24's Face Sheet indicated the facility originally admitted the resident on 7/16/2020 and readmitted the resident on 3/31/2022 with diagnoses including traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain which may result to disability or death), dysphagia (a condition in which swallowing is difficult or painful), percutaneous endoscopic gastrotomy (PEG - also known at GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement, and chronic respiratory failure (a long-term condition in which the lungs have a hard time loading the blood with oxygen which may result to low oxygen level). A review of Resident 24's History and Physical (H&P), dated 11/3/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/29/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 24's Morse Fall Risk Assessment every shift dated 4/11/2024, 4/12/2024, 4/13/2024, and 4/14/2024, indicated the resident was a medium risk for falls and a high risk for injury. A review of Resident 24's Order Reports did not indicate an order for use of four side rails. A review of Resident 24's care plan did not indicate any plan of care for the use 4 bed SR up. A review of Resident 24's electronic every shift assessment by licensed nurses dated 03/01/2024-04/14/2024, did not indicate the resident was assessed for risk of entrapment prior to use of four side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 38 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 SRs. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 4/13/2024 at 10:15 a.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 24 in bed with four SR up. LVN 3 stated the resident places her right leg over the SR most of the time and placing four SR in raised up position is for the safety of the resident. LVN 3 stated the resident is at risk for falls and the SR prevent the resident from falling. Residents Affected - Some During a concurrent observation and interview on 3/13/2024 at 10:39 a.m., with Registered Nurse 2 (RN 2), RN 2 stated Resident 24's four bed SR were placed in raised position while in bed for the resident's safety, to prevent falls and possibly injury as resident moves a lot in the bed. During a concurrent interview and record review on 4/13/2024 at 4:00 p.m., with the Infection Preventionist (IP), Resident 24's medical record including assessments, physician orders and informed consents were reviewed. The IP verified the facility did not have an assessment, physician's order, and consent for the use of four bed SR up while in bed because the facility does not consider SR as restraints. During an interview on 4/14/2024 at 1:15 p.m., with the Nurse Clinician (NC), the NC stated the use four SR up while the resident is in bed is considered use of a restraint. The NC stated there should have been an order from the physician and assessment for entrapment risk for SR use prior to use of four SR up. During an interview on 4/14/2024 at 1:17 p.m., with the Nurse Manager (NM), the NM stated placing the resident's all four SR up is considered use of a restraint and there should have been an order from the physician and assessment for entrapment risk for SR use. The NM stated it is important to notify the Resident 24's representative of the risks and benefits of using four SR up so they (representative) would be aware of the potential risks from using the SR such as restriction of movement, decline in functioning and entrapment which may lead to injuries. A review of the facility provided manufacturer's guideline for Hospital Bed 1 (HB 1), undated, indicated a Warning- Evaluate patients for entrapment and fall risk according to facility protocol, and/or healthcare provider directives, and monitor patients appropriately. Make sure all siderails are fully latched when in the raised position. Failure to do either of these could cause serious injury or death. A review of the facility provided manufacturer's user manual for Hospital Bed 2 (HB 2), copyright 2005, indicated evaluate patients for entrapment risk according to facility protocol, and monitor patients appropriately. Make sure that all siderails are fully latched when in the raised position. Failure to do either of these could result in serious injury or death. A review of the facility's recent policy and procedure titled, Restraint Use (Sub Acute), last revised on 2/2024, indicated in keeping with the mission and values of Providence of Providence Health & Services, it is the policy of Providence Holy Cross Medical Center (PHCMC) to guide care givers on appropriate and safe management of residents with restraints and utilization of least restrictive alternatives. To ensure safe and ethical practice for the use of physical restraints in the Sub-Acute Unit and that no person will be restrained against their will for any period longer than necessary. Restraints are considered medical devices and are only used in the event that the patient is a danger to self or others. Consent for restraint is signed by legal representative/decision-maker. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 39 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm licensed nurse will assess the patient and attempt to find less restrictive alternatives to restraint. Licensed healthcare practitioner order is required; orders for restraints obtained by telephone will be signed by the physician within five days; restraints are reordered every 30 days if continued need is assessed. Documentation on restraints will include device(s): Residents Affected - Some a. Bed rails X 4 b. Mittens, including Peek-a-Boo mitt. c. Mittens d. soft wrist restraints e. Assessment for continued need 2. A review of Resident 23's Face Sheet indicated the facility admitted the resident on 3/13/2024, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History and Physical (H&P), dated 4/3/2024, indicated the resident had history of post traumatic cervical-spine injury (involves damage to any part of the spinal cord), and quadriplegia (a life-altering condition that results in a loss of control of both arms and both legs). The H&P indicated the resident was on a ventilator (a machine that helps a person breathe) with occasional grunting. A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/20/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. A review of Resident's Fall Risk Assessment (FRA), dated 4/14/2024, indicated the resident was medium risk for fall and high risk for injury. The FRA did include documentation of the resident using four side rails up in bed. A review of Resident's Care Plan titled, Problem: Fall Injury Risk, undated, indicated an intervention to avoid use of devices that minimize mobility, such as restraints. During a concurrent observation and interview on 4/13/2024, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 23's room, observed Resident 23 in bed with four SR in raised position. LVN 1 stated the resident's bed had all four side rails up to prevent injuries resulting from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 40 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm falls. LVN 1 stated a physician's order and consent from the resident's representative should be obtained prior to SR use. LVN 1 further stated the resident was not assessed for risk of entrapment and there was no documentation that the risks and benefits of using a SR was reviewed with the resident or the resident representative. LVN 1 stated failure to assess the resident for risk of entrapment can result to accidents such as strangulation from the SR. Residents Affected - Some A review of the facility provided manufacturer's guideline for Hospital Bed 1 (HB 1), undated, indicated a Warning- Evaluate patients for entrapment and fall risk according to facility protocol, and/or healthcare provider directives, and monitor patients appropriately. Make sure all siderails are fully latched when in the raised position. Failure to do either of these could cause serious injury or death. A review of the facility provided manufacturer's user manual for Hospital Bed 2 (HB 2), copyright 2005, indicated evaluate patients for entrapment risk according to facility protocol, and monitor patients appropriately. Make sure that all siderails are fully latched when in the raised position. Failure to do either of these could result in serious injury or death. A review of the facility's recent policy and procedure titled, Restraint Use (Sub Acute), last revised on 2/2024, indicated in keeping with the mission and values of Providence of Providence Health & Services, it is the policy of Providence Holy Cross Medical Center (PHCMC) to guide care givers on appropriate and safe management of residents with restraints and utilization of least restrictive alternatives. To ensure safe and ethical practice for the use of physical restraints in the Sub-Acute Unit and that no person will be restrained against their will for any period longer than necessary. Restraints are considered medical devices and are only used in the event that the patient is a danger to self or others. Consent for restraint is signed by legal representative/decision-maker. The licensed nurse will assess the patient and attempt to find less restrictive alternatives to restraint. Licensed healthcare practitioner order is required; orders for restraints obtained by telephone will be signed by the physician within five days; restraints are reordered every 30 days if continued need is assessed. Documentation on restraints will include device(s): a. Bed rails X 4 b. Mittens, including Peek-a-Boo mitt. c. Mittens d. soft wrist restraints e. Assessment for continued need (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 41 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/28/2021, with diagnoses including gastrointestinal (GI, relating to, or including both the stomach and intestine) bleed. A review of Resident 5's H&P, dated 8/18/2023, indicated the resident had pedestrian accident sustaining bilateral subarachnoid hemorrhage (SAH, a bleeding in the space below one of the thin layers that cover and protect the brain), left subdural hemorrhage (SDH, a buildup of blood on the surface of the brain), with multiple facial bone fracture (partial or complete break in the bone). The H&P indicated the resident was awake and interactive. The H&P also indicated the resident had agitation and delirium (a mental state in which a person is confused and has reduced awareness of their surroundings) being evaluated by a psych specialist. A review of Resident 5's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. A review of Resident 5's FRA, dated 4/14/2024, indicated the resident was assessed as medium risk for fall and use of bed alarm was in place, The FRA did not indicate use of all four side rails up. A review of Resident 5's Care Plan titled, Problem: Fall Injury Risk, initiated on 8/2/2023, indicated the resident had a fall episode found resident sitting on the floor, at the right side of the bed. The Care Plan had an intervention to use side rail pad to both rails as needed. During a concurrent observation and interview on 4/13/2024, at 10:55 a.m., with Licensed Vocational Nurse 2 (LVN 2), in Resident 5's room, observed Resident 5 in bed with four SR in raised position. LVN 2 stated the resident's bed had all four side rails up to prevent the resident from falling. LVN 2 stated there was no physician's order, assessment for entrapment risk and consent from the resident's representative prior to SR use. During a concurrent interview and record review on 4/13/2024, at 2:13 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 5's All Active Orders, Flow Sheet, and Media. RN 4 stated there was no documented evidence of informed consent for side rails and entrapment risk assessment for side rail use. RN 4 stated the resident's bed had all four side rails up to prevent falls. During an interview on 4/14/2024, at 1:15 p.m., with the Nurse Clinician (NC), the NC stated use of four side rails up is considered use of a restraint and required an order from the physician. The NC also stated the resident should have an assessment for side rail use to ensure safety. During an interview on 4/14/2024, at 1:17 p.m., with the Nurse Manager (NM), the NM stated placing the resident's all four SR up is considered use of a restraint. The NM stated a physician's order, an assessment for entrapment risk, and consent from the resident or the resident representative (RR) should be in place prior to use of side rails. The NM stated the resident, or the RR should be informed of the risk and the benefits of using the restraints prior to application. The NM stated failure to assess the resident for risk of entrapment had the potential to result in entrapment from SRs. A review of the facility's recent policy and procedure titled, Restraint Use (Sub Acute), last reviewed on 2/2024, indicated restraints are considered medical devices and are only used in the vent that the patient is a danger to self or others. Consent for restraint is signed by legal representative/decision maker. Documentation on restraints will include device(s): (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 42 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 a. Level of Harm - Minimal harm or potential for actual harm Bed rails X 4 Residents Affected - Some A review of the facility provided manufacturer's guideline for Hospital Bed 1 (HB1), undated, indicated a Warning- Evaluate patients for entrapment and fall risk according to facility protocol, and/or healthcare provider directives, and monitor patients appropriately. Make sure all siderails are fully latched when in the raised position. Failure to do either of these could cause serious injury or death. A review of the facility provided manufacturer's user manual for Hospital Bed 2 (HB 2), copyright 2005, indicated evaluate patients for entrapment risk according to facility protocol, and monitor patients appropriately. Make sure that all siderails are fully latched when in the raised position. Failure to do either of these could result in serious injury or death. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 43 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility: 1.Failed to ensure licensed nurse did not leave an insulin pen (an injection device that you can use to deliver preloaded insulin [controls the amount of sugar in the blood by moving it into the cells, where it can be used by the body for energy]) unattended on top of a computer on wheels (WOW). This deficient practice had the potential to result in unwanted serious side effects if placed in undesired hands which can lead to harm. 2.Failed to ensure licensed nurses' account of a controlled drug record (accountability record of medications that are considered to have a strong potential for abuse) was accurately documented per facility policy for one of two sampled residents. This deficient practice had the potential for medication errors. Findings: a. During an observation on 4/13/2024 at 12:09 p.m., observed Licensed Vocational Nurse 3 (LVN 3) place an insulin pen on top of a computer on wheels (wow). Observed LVN 3 walked away from the wow entering a resident's room, leaving the insulin pen unattended. During an observation and concurrent interview on 4/13/2024 at 12:23 p.m., Licensed LVN 3 stated that she left the insulin pen unattended on top of the wow while she entered a resident's room. LVN 3 stated that she should always have all medication with her at all times for safety. LVN 3 further stated that she should not have left the insulin pen on top of the wow unattended. A review of the facility's policy and procedure titled, Medication Administration and Monitoring (Sub Acute), revised 3/2024, indicated medications are removed from the medication cart for one resident at a time. Once removed, medications must remain with the administering staff at all times and not left unattended. b. A review of Resident 11's admission Record indicated the facility admitted the resident on 12/8/2023 with diagnosis that included respiratory failure (a serious condition that makes it difficult to breathe on your own) and seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain). A review of Resident 11's Physician's Order dated 12/11/2023 indicated Lacosamide (Vimpat- to treat partial-onset seizures) 10 milligram (mg - unit of measurement)/milliliter (mL - unit of measurement) liquid 150 mg. Per g-tube (gastrostomy tube -a tube inserted through the belly that brings nutrition directly to the stomach) every morning. A review of Resident 11's Physician's Order, dated 12/11/2023, indicated Lacosamide (Vimpat) 10mg/mL liquid 200 mg. Per g-tube nightly. A reviewed of Resident 11's controlled-drug record for Lacosamide (Vimpat) 10mg/mL solution indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 44 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 - Level of Harm - Minimal harm or potential for actual harm Date: 3/8/2024; Administered Time: 8:15 p.m.; Administered Amount: 20; Amount Remaining: 20 - Residents Affected - Few Date: 3/9/2024; Administered Time: 9:00 a.m.; Administered Amount: 15; Amount Remaining: 5 During an interview and concurrent record review with Registered Nurse 3 (RN 3) on 4/13/2024 at 3:56 p.m., RN 2 reviewed Resident 11's controlled-drug record and stated that Resident 11's controlled drug record for Lacosamide (Vimpat) not accurate. RN 3 stated that on 3/8/2024 20 mL was administered and on 3/9/2024 15 mL was administered, remaining should have been 10 mL, not 5 mL. RN 3 stated that licensed nurses should have checked the bottle and levels carefully to ensure that the accurate amount in the bottles matches what is documented on the controlled drug record at the start of every shift. During an interview and concurrent record review with the Nurse Manager (NM) on 4/13/2023 at 7:01 p.m., the NM reviewed Resident 11's controlled drug record and stated that Resident 11's controlled drug record for Lacosamide (Vimpat) count is wrong. Amount remaining should have been 10 mL not 5 mL. Staff should have identified the discrepancy in the beginning of the shift and reported the discrepancy per the facility's policy. A review of the facility's policy and procedure titled, Controlled Medication Storage, dated 8/2014, indicated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. At each shift change, physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. Any discrepancy in controlled substance medication count is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents irreconcilable discrepancies in a report to the administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 45 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure if needed (PRN) orders for psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, and behavior) were only used when the medication was necessary and PRN use was only limited to two of five residents (Residents 23 and 5) selected for unnecessary medications review. The deficient practice had the potential to result in the use of unnecessary psychotropic drugs for residents and can lead to side effect and adverse (unwanted) consequence such as a decline in quality of life and functional capacity. Findings: 1. A review of Resident 23's Face Sheet (admission Record) indicated the facility admitted the resident on 3/13/2024, with a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History and Physical (H&P), dated 4/3/2024, indicated the resident had a history of post traumatic cervical-spine injury (involves damage to any part of the spinal cord), quadriplegia (a life-altering condition that results in a loss of control of both arms and both legs), and septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). The H&P indicated the resident was on a ventilator (a machine that helps a person breathe) with occasional grunting. A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/20/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 23 had an active diagnosis of depression. A review of Resident 23's All Active Orders, dated 3/14/2024, indicated an order for lorazepam (Ativan, used to treat anxiety) tablet 0.5 milligrams (mg, a unit of weight) per gastrostomy tune (g-tube, a tube inserted through the wall of the abdomen directly to the stomach) every 6 hours PRN. PRN reasons: Anxiety Admin instructions: diagnosis (Dx) Anxiety monitor for behavior (m/b) hyperventilation (rapid or deep breathing) leading to shortness of breath (SOB). A review of Resident 23's Consultant Pharmacist's Medication Regiment Review (MRR) between 1/1/2024 and 1/30/2024, indicated the medications were reviewed by the consultant pharmacist. The MRR created between 2/1/2024 and 2/29/2024, indicated a recommendation from the pharmacist the resident has an order for PRN Ativan 0.5 mg. Please, specify the stop date. A new order can be written if the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication and documents their rationale in the resident's medical record and indicates the duration for the PRN order. During a concurrent interview and record review on 4/14/2024, at 7:55 p.m., with the Nurse Manager (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 46 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (NM), reviewed the Active Orders and the Medication Regimen Review pharmacist recommendations for Resident 23 with the NM. The NM confirmed the following orders for Resident 23, 3/14/2024 lorazepam (Ativan) tablet 0.5 mg per g-tube every 6 hours PRN without an end date. The NM also reviewed the MMR created between 2/1/2024 and 2/29/2024 for Resident 23 indicating a recommendation from the pharmacist the resident has an order for PRN Ativan 0.5 mg, please specify the stop date. The NM stated the lorazepam order for Resident 23 did not have a stop date and the pharmacist recommendation was not followed up. The NM stated psychotropic drugs such as the lorazepam should only be good for 14 days duration. The NM stated prolonged use of psychotropic medications can result in the use of unnecessary psychotropic drugs for residents and can lead to unwanted side effects, dependency on the drug that can lead to a decline in quality of life and functional capacity. A review of the Consultant Pharmacist's Medication Regiment Review between 1/1/2024 and 1/30/2024, indicated the medications were reviewed by the consultant pharmacist. Recommendations created between 2/1/2024 and 2/29/2024 indicated Resident 23 has an order for PRN Ativan 0.5 mg. Please, specify the stop date. A new order can be written if the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication and documents their rationale in the resident's medical record and indicates the duration for the PRN order. A review of the Pharmacist Consultant Summary Report for February 2024, indicated on E. Psychotropic Medications (F-tag 758), PRN Antipsychotic orders are always only x 14 days. A review of the facility's recent policy and procedure titled, Psychotropic Drugs (Sub Acute), last reviewed on 2/2024, indicated PRN psychotropic medications will have a start and stop date for 14 days initially then re-evaluated by MD. If needed to be continued, medication will be ordered for three months. The residents will have a monthly review documenting all behavior episodes for that month. 2. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/28/2021, with a diagnosis of gastrointestinal (GI, relating to, or including both the stomach and intestine) bleed. A review of Resident 5's H&P, dated 8/18/2023, indicated the resident had agitation and delirium (a mental state in which a person is confused and has reduced awareness of their surroundings) being followed up by a psych specialist. The H&P indicated the resident was awake and interactive. A review of Resident 5's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. A review of Resident 5's All Active Orders, dated 1/24/2024, indicated an order for lorazepam (Ativan) 1 tablet per g-tube every 12 hours PRN, with a start date of 1/24/2024 and stop date of 4/23/2024. PRN reasons: Anxiety Admin instructions: Dx; Anxiety m/b throwing objects on the floor, pulling out medical devices. During a concurrent interview and record review on 4/14/2024, at 7:55 p.m., with the Nurse Manager (NM), reviewed the Active Orders and the Medication Regimen Review pharmacist recommendations for Resident 5 with the NM. The NM confirmed for Resident 5, lorazepam (Ativan) 1 tablet per g-tube every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 47 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12 hours PRN, with a start date of 1/24/2024 and stop date of 4/23/2024 more than 14 days of effectivity. The NM stated the lorazepam order for Resident 5 had more than 14 days effectivity of the order. The NM stated psychotropic drugs such as the lorazepam should only be good for 14 days duration. The NM stated prolonged use of psychotropic medications can result in the use of unnecessary psychotropic drugs for residents and can lead to unwanted side effects, dependency on the drug that can lead to a decline in quality of life and functional capacity. A review of the Consultant Pharmacist's Medication Regiment Review between 1/1/2024 and 1/30/2024, indicated the medications was reviewed by the consultant pharmacist. Recommendations created between 2/1/2024 and 2/29/2024 indicated the resident had an order for PRN Ativan 0.5 mg. Please, specify the stop date. A new order can be written if the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication and documents their rationale in the resident's medical record and indicates the duration for the PRN order. A review of the Pharmacist Consultant Summary Report for 2/2024, indicated on E. Psychotropic Medications (F-tag 758), PRN Antipsychotic orders are always only x 14 days. A review of the facility's recent policy and procedure titled, Psychotropic Drugs (Sub Acute), last reviewed on 2/2024, indicated PRN psychotropic medications will have a start and stop date for 14 days initially then re-evaluated by MD. If needed to be continued, medication will be ordered for three months. The residents will have a monthly review documenting all behavior episodes for that month. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 48 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by: Residents Affected - Some 1. Failing to ensure food service attendant wore a hair restraint while working in the food production line. 2. Failing to ensure food items not in their original package were labeled and dated. 3. Failing to ensure an open food product that is in its original packaging was labeled and dated. These deficient practices had the potential to place six out of 43 residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). 1.During an initial observation of the kitchen on 4/13/2023 at 8:14 a.m., observed a Food Service Attendant (FSA) working in the food production line placing food on meal trays, not wearing a hair restraint. During an observation and concurrent interview with the FSA on 4/13/2024 at 8:16 a.m., the FSA stated that he was not wearing a hair restraint. When asked when he is supposed to wear a hair restraint, the FSA stated that once he clocks in for work at 5:00 a.m. and upon entering the kitchen, the FSA is supposed to wear a hair restraint. The FSA further stated that hair restraints are important to wear so that hair does not fall into the food. The facility policy and procedure titled Dress Code, revised on 10/8/2019. Indicated it is the policy of Providence Holy Cross Medical Center Food and Nutrition Services Department that all employees are required to dress accordingly to the approved dress code at all times. Purpose: To avoid contamination of food, establish departmental identification and present a professional appearance. Under universal Dress Requirements: A. In food production, storage and serving areas, hair restraints must be worn: a hairnet, skull cap, or beret. 2. During an observation of refrigerator 1-2 on 4/13/2023 at 8:25 a.m., observed open food items not in its original packaging placed in a clear storage bag without a label or date. During observation an observation and concurrent interview with the Kitchen Supervisor (KS) on 4/13/2024 at 8:29 a.m., the KS stated that the open food items were not in its original packaging placed in a clear storage bag without a label or date. When asked what the food item was, the KS stated there were multiple pieces of cheddar cheese. The KS stated that when a food item is not in its original packaging the food item must be labeled with the specific name of the food item, the date when the food item was opened, and the initials of the food service attendant that opened the product. When asked about the importance of accurate labeling the KS stated that it is important to accurately label food items to make sure that the food item is what is and for the safety of our residents. 3.During an observation of refrigerator 1-2 on 4/13/2023 at 8:33 a.m., observed an open package of low moisture part-skim mozzarella cheese open without an open date. During observation an observation and concurrent interview with the KS on 4/13/2024 at 8:35 a.m., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 49 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the KS stated that the open package of low moisture part-skim mozzarella cheese is not labeled with an open date. The KS stated that once a food item is open the food item should be labeled with an open date to make sure we use the food item before it expires. This is to ensure resident safety. A review of the facility provided policy and procedure titled Label and Dating, 1/9/2019, indicated the Food and Nutrition Services shall ensure that foods are label, dated and stored appropriately. Purpose: To ensure the proper storage and safely of the department's food supply. Products will be dated via the following acceptable mechanisms: A Label with the following information will be used to label and date foods for holding and storage. 1). Item name; 2) Use by date (pull date); 3) Employee Signature. Event ID: Facility ID: 555074 If continuation sheet Page 50 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff failed to implement its infection control program to two out of 23 sampled residents (Residents 5 and 3) during resident screening by failing to ensure: Residents Affected - Few 1. The suction canister (a temporary storage container for secretions or fluids removed from the body) of Resident 5, labeled 4/5/2024 was discarded and replaced per facility policy. 2. The urinal bottle (frequently used in healthcare for residents who find it impossible or difficult to get out of bed) was labeled with the name, date, and room number of Resident 3. These deficient practices had to potential to spread infection among residents. Findings: 1. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/28/2021, with a diagnosis of gastrointestinal (GI, relating to, or including both the stomach and intestine) bleed. A review of Resident 5's History and Physical (H&P), dated 8/18/2023, indicated the resident had a history of coronary artery bypass graft (CABG, a medical procedure to improve blood flow to the heart), craniotomy (a surgical procedure in which a part of the skull is temporarily removed to expose the brain), and tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs). The H&P indicated the resident was awake and interactive. A review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/23/2024, indicated the resident sometimes had the ability to make self-understood and understand others. During a concurrent observation and interview on 4/13/2024, at 10:55 a.m., with Licensed Vocational Nurse 2 (LVN 2), inside Resident 5's room, observed the suction canister of the resident dated 4/5/2024. LVN 2 stated the suction canister should be changed weekly to prevent the growth and transmission of infection among residents. During an interview on 4/14/2024, at 8 p.m., the Nurse Manager (NM) stated the suction canister should have been changed on 4/12/2024. The NM stated the suction canisters were changed weekly to prevent growth of bacteria on the suction canisters that could cause infection to vulnerable residents. A review of the facility's recent policy and procedures titled, Mechanical Ventilation, Monitoring and Care, Long-term Care, last reviewed on12/11/2023, indicated for suction canister, replacement schedule was weekly and when three quarters full and the supply should be dated and initialed. 2. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 8/2/2023, with a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 3's H&P, dated 5/10/2023, indicated the resident had history of status post (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 51 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (s/p) tracheostomy and stage 1 sacral pressure injury (observable, pressure-related redness of a localized area usually over a bony prominence such as the sacrum [tailbone]). The H&P indicated the resident was awake, interactive, moves all extremities, with generalized weakness. A review of Resident 3's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. During a concurrent observation and interview on 4/13/2024, at 9:30 a.m., with Certified Nursing Assistant 3 (CNA 3), inside Resident 3's room, observed two unlabeled urinal bottles hanging at the left side rail of the resident's bed. CNA 3 stated the urinals should be labeled with the name, date, and room number of the resident so they know when to change them and to prevent interchanging urinals that could cause infection. During an interview on 4/14/2024, at 8 p.m., the Nurse Manager (NM) stated the staff should label the urinal with date, room number, and the name of the resident to know when to change the urinals and to prevent switching urinals with other residents to prevent infection. A review of the facility's recent policy and procedure titled, General Acute Care Hospital 1 (GACH 1) Department of Epidemiology & Infection Prevention 2024 Scope of Service, Surveillance Plan, Risk Assessment, and 2023 Program Evaluation, undated, indicated infection control is multi-disciplinary, systemic approach to quality patient care that emphasizes risk reduction of disease transmission in a health care environment. It can further be defined as the establishment of a program or a plan of action to prevent disease transmission in those cases that cannot be prevented. This is accomplished by setting controls or standards that have been proven to be effective in minimizing those infections that cannot be prevented, preventing those that can be, and providing early diagnosis and appropriate treatment of all infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 52 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement its policy and procedures for antimicrobial stewardship (AMS- a coordinated program that promotes the appropriate use of antimicrobials [including antibiotics, drugs used to treat infections caused by bacteria and other microorganisms], improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms) for one of six sampled residents (Resident 2) when clindamycin (an antibiotic) was ordered on 1/29/2024 as indefinite and the facility failed to monitor the antibiotic use for 77 days. Residents Affected - Some This deficient practice had the potential for the resident to receive an inappropriate antibiotic and develop antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections). Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 12/28/2023. Resident 2's diagnoses included history of multidrug resistant pseudomonas proteus (bacteria that have become resistant to certain antibiotics) and methicillin-resistant staphylococcus aureus (MRSA- is a cause of staph infection that is difficult to treat because of resistance to some antibiotics), quadriplegia (a form of paralysis that affects all four limbs, plus the torso), and multiple sclerosis (MS-a long-lasting [chronic] disease of the central nervous system). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/22/2023, indicated the resident's cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills for daily decision-making was intact. A review of the Physician's Orders for Resident 2 dated 1/29/2024 indicated clindamycin 1% gel two times a daily for chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) unspecified whether with hypoxia (deficiency in the amount of oxygen reaching the tissues) or hypercapnia (elevation of carbon dioxide in the blood). Length of therapy indicated indefinite. A review of Resident 2's Medication Administration Record (MAR- is a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) for clindamycin 1% gel two times a daily for chronic respiratory failure unspecified whether with hypoxia or hypercapnia indicated: January 2024: given 5 times (9 a.m. and 9 p.m.). February 2024: given 58 times (9 a.m. and 9 p.m.). March 2024: given 62 times (9 a.m. and 9 p.m.). April 2024: given 27 times (9 a.m. and 9 p.m.). During a concurrent interview and record review, on 4/14/2024 at 2:41 p.m., with the Infection Preventionist (IP) of Resident 2's Physician Orders, the IP stated Resident 2 was on clindamycin topically (to the skin). The IP stated the order indicated clindamycin was ordered indefinitely by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 53 of 54 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm dermatologist on 1/29/2024 for folliculitis (skin condition that happens when hair follicles become inflamed). The IP stated antibiotics should not be used indefinitely, antibiotics should have a stop date. The IP stated antibiotics require a stop date to ensure the resident does not develop a resistance to the antibiotics. The IP stated Resident 2's clindamycin should have been included in the antibiotic stewardship program, and that if its use had been documented, they could have caught the indefinite length of treatment. Residents Affected - Some During an interview, on 4/14/2024 at 6:28 p.m., the Nurse Manager (NM) stated Resident 2 should not have any antibiotic with an indefinite order; the use of antibiotic should have a time frame to determine the efficacy (effectiveness). The NM stated there is a concern with the antibiotic drug resistance when the antibiotic order does not have an end date. The NM stated the antibiotic stewardship was created to monitor antibiotic use. A review of the current facility-provided policy and procedure (P&P) titled, Antimicrobial Stewardship (AMS) Program, last revised in 06/2023, indicated to implement a comprehensive antimicrobial stewardship program to evaluate judicious use of antimicrobials. The purpose of the policy is to achieve the following AMS program goals and objectives: 1. Optimize antibiotic therapy to improve clinical outcome while minimizing unintended consequences of antimicrobial use, such as drug toxicity and emergence of resistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 54 of 54